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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton. Av'e. , Stockton, Calif. <br /> Telephone:. (209) 466--6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- Yr.,.� THIS PERMIT EXPIRES 1, YEAR FROM-DATE ISSUED Date Issued <br /> { <br /> (Complete- In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District .fora permit to construct <br /> and/or install the work herein described. This .application is .made in- compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and.:.Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / 11LL7�- __ �raZ��Lo __ CENSUS TRACT <br /> r <br /> Owner's Name Phone <br /> A <br /> i Address City. . ll# --- <br /> 3; <br /> Contractor's Name �.., License # ly3 ?y �Mone . —2�74 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /� <br /> /' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> r Domestic/public `` Driven Gauge of Casing <br /> I, 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 of Pump H.P. <br /> PUMP REPLACEMENT: / / , SState Work Done <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t <br /> Describe'Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local HealthDistrict <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 <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 wled e an lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND A FINAL IN I <br /> SIGNED TLE rte' <br /> (DXArW LO PLAN ON REV RSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G 0 ECTION PHASE III/FINAL IN PECTION <br /> INSPECTION BY DATE -INSPECTION BY TE <br /> b177 '2M <br /> E�-H 1426 Rev. . 1-74 _ <br />