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„ � ,,.,SAN JOAQUIN LOCAL HEALTH DISTRICT � F <br /> FO$.OFMCE USE; 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209)' 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77k”/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> j (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'Ordi �ce�No. e u es Regulations of the San Joaquin Local Health District. <br /> JOB ADDRES LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> s Address <br /> r' City <br /> Contractor's Name . License Phone <br /> TYPE OF WORK (Check) : NEW WELL 13;r, DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> E PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT_FT <br /> Other 4/ / <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s d <br /> SEWAGE DISPOSAL�IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE V PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool Dia. of Well Excavation , <br /> Domestic/private Drilled Dia. of Well Casing p� <br /> Domestic/public Driven <br /> Gauge of Casing lam' <br /> { Irrigation Gravel PackDepth of Grout Seal --`— <br /> Cathodic Protection:„ Rotary Type of Grout <br /> Disposal Dis 9` <br /> p �Otlier Other Information <br /> Geophysical Surface Seal Installed B Y. <br /> PUMP INSTALLATION: Contractor /f1ce- <br />` Type of Pump _ <br /> H.P. / <br /> 4 PUMP REPLACEMENT; State Work Done <br />' PUMP .REPAIR: /_./ State Work Done <br /> c <br /> DESTRUCTION OF WELL: Well' Diameter <br /> Describe Material and Procedure Approximate Depth <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 DAIS <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 ell and notify them before putting the well in use. The above <br /> information is true o e best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ON. <br /> SIGNED �z TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY T <br /> ADDITIONAL COMMENTS: ��_-� ,o DAT <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III/FIN INSP CTION <br /> DATE INSPECTION BY DATE jjL L-1 <br /> 4 ;.yam <br /> E -H 1426 Rev. 1-74 a 1177 _ 2M <br />