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1*-9A 71 <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP • i <br /> OFFICE USE: 1601_ E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 ® ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A7 8� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � � CENSUS TRACT <br /> Owner's Name hone <br /> Address City ' <br /> Contractor's NameLicense Phone. <br /> i <br /> TYPE OF WORK (Check) : NEW.„WELL / f DEEPEN/ ./ RECONDITION / / DESTRUCTION /_7 <br /> PUMP. INSTALLATION X1 PUMP REPAIR / / PUMP REPLACEMENT j <br /> 0 then. / / a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _PROPERTY LTNE': {PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE--' TYPE OF 'WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial ' ' Cable Tool Dia. of Well Excavation 1 <br /> Domestic/private Drilled Dia, of Well Casing W <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information— <br /> Geophysical Surface Seal Installed BY : <br /> PUMP INSTALLATION: Contractor <br /> * Type sof,PIMP751 — ” H.P. <br /> PUMP REPLACEMENT: / State Wark DoneAw <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material :and_.P_ro.cedure . <br /> I hereby agree to comply with all laws and, regulatibn6 of the SanjJoaquin Local Health istrict <br /> and the State of California pertaining to or `tegulating 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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />.PRIOR TO ROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY �• DATE '✓9��y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F u IL9A D- I--7L 1/77 " 2M <br />