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SAN JOAQUIN LOCAL:HEALTH DISTRICT - _ <br /> FOA OFFICE USE: 1601 E. Hazelton Ave. , Stockton', Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77`.30, <br /> r#4, <br /> / THIS PERMIT EXPIRES 1 YEAR-PROM DATE' ISSUED Date Issued .3-7 <br /> (Complete In Triplicate)` <br /> Application ie heiiby made to the San Joaquin Local. Heal.�th District for a permit to construct <br /> i <br /> and/or install the work herein described.. This application is made in compliance with San Joaquin <br /> County Ordinance No.'-3862 and the Rules <br /> Ruless and -Regulationse,of- i e 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,,9 Q c3 3 �7�' .i/ 1 TEl �I0 CENSUS TRACT <br /> k Owner's Name Phone <br /> Address,' Sj :��� �� .. . � City LSC -1 <br /> Contractor's Name v License Phone �T <br /> TYPE OF WORK .(Check.).: NEW WELL -7. DEEPEN -/_7 RECONDITION l_T DESTRUCTION /7 <br /> PUMP INSTALLATION 1' PUMP REPAIR /7 PUMP REPLACEMENT 17 <br /> Other E/ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT-PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL ' ` PUBLIC DOMESTIC WELL <br /> INTENDED USE jjXPE.OF' WELL CONSTRUCTION SPECIFICATIONS {` <br /> Industrial ` ' ' ~' Cable Tool Dia. of Well Excavation <br /> Domes tic/pr-ivate Dr#11ed­--^ Dia:of-Well :Casing <br /> Domestic/Public' Driven,\y Gauge of Casing <br /> Irrigation Gravel, Pack� Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ' Disposal Other . ,Other Information <br /> r Geophysical. I Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor Al <br /> Type of Pump : .4 H.P. /. <br /> PUMP REPLACEMENT: � i_/`State Work Done <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> - - - ---�-�-Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San, Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of.:-.my work on a new well, I will furnish the .San Joaquin Local Health District a <br /> WELL DRILLERS -REPORT of the well and notify them before putting. the well in use.. The above <br /> information is true to thembest` of my .knowledge-and belief.` I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D�;.A�F AL NSPE <br /> SIGNED iCTION.,,. , <br /> `._ . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDA4 <br /> FOR DEPARTMENT USE ONLY... <br /> • PHASE I <br /> APPLICATION ACCEPTED BY t .4DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION "P II IAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BDATE <br /> pu <br /> t E H 1426 Rev. 1-74 1:74 2M <br />