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V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FMOE}rk 'ICE .USE: 1601 E. Hazelton Ave. , Stockton, Calif. •, F <br /> Telephone :: <br /> p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 713 eJ <br /> E <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 eRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r 131 1L EP B&P CENSUS TRACT <br /> Owner's Name ` Phone 7 <br /> Address — 31 [. Q City � C <br /> Contractor's Namef ' �' <br /> L -.License It Phone`` S� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ? SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,kadustrial Cable Tool Dia. of Well Excavation <br />` Domestic/private Drilled Dia, of Well Casing (y <br /> Domestic/publicGravel Pack <br /> Gauge-of Casing:`_. <br /> Irrigation 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: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done } <br /> DESTRUCTION OF WELL:f� Weli biameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Loca1--Health District <br /> and the State of California pertaining to or regulating well 'constructiori:_ 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 c <br /> informat n is true to the best of my knowledge and belief. I WILLICALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING INSACTION. <br /> SIGNED AfA TITLE— ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i E <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> n - <br /> APPLICATION ACCEPTED BY lm� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 'II -GROUT 'INSPECTION - -- - - - - PHASE,,II•I/FINAL INSPECTION -_ <br /> INSPECTION BY DATE INSPECTION BY ,� _ DATE / ' ,3 <br /> E H 1426 Rev. -I-74 ' 1177 _ 2M <br />