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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: A91 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (2.09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- =1J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- <br /> (Complete <br /> (Complete In Triplicate) <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> t. and/or install the' work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules d gulatiopq of the San Joaquin Local Health District. <br /> E JOB ADDRESS/LOCATION �v CENSUS TRACT ry <br /> Owner's Name Phone <br /> Adaress C.J City <br /> Contractor's Name , License � = f Phone <br /> i <br /> TYPE OF WORK (Check) : NEW 'WELL DEEPEN '/—/ RECONDITION_/ / DESTRUCTION /7 <br /> PUMP INSTALLATION./ / -PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other 1_7 <br /> : k <br /> DISTANCE TO NEAREST: SEPTIC TANK r-SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE}PIT ._ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC'WELL <br /> ­-INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial }Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection . > Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> i Geophysical Surface Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / ,'.State Work Done <br /> PUMP .REPAIR: I I State Work Done., <br /> DESTRUCTION OF WELL: Welj� 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 /> f 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 G OUTING MD AOIN4 INSPECTION. <br /> SIGNED TITLE <br /> -` DRAW PL b T' PLAN 'ON REVERSE SIPS) <br /> FOR DEPARTMENT USE`ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:, <br /> PHA E II GROUT�INSPECTI J PHAS9 III/F NAL INSPECTION*, <br /> INSPECTION BY DATE- INSPECTION BY` DATE <br /> 4 101-7 <br /> 0 1-7/77 <br /> E H 1426 Rev. 1-74 / j?on,,D G �•�� 3/76 2M <br />