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�AN JOAQUIN LOCAL HEAL'T'H DISTRICT <br /> FOBMFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 9a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> pq- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Diatrict 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 /> k JOB ADDRESS/LOCATION �'�� Z 2 7-3 r 1? 7/' E/G T � II& 4E' 2 CENSUS TRACT <br /> Owner°s Name Phone <br /> �J <br /> 1931- <br /> i <br /> Address r City <br /> Contractor's Name License �.� ,x Phone <br /> TYPE OF WORK (Check) : NEW WELLIV DEEPEN RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /_7 PUMP REPAIR / / PUMP REPLACEMENT . <br /> Other` /_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> K PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing '• c <br /> Domestic/public Driven Gauge of Casing i <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 of Pump H.P. <br /> PUMP REPLACEMENT: / `/ State Work Done <br /> PUMP .REPAIR _ L7 ..State Work Done <br /> ES-TRUCTION OF WELL: Well 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 /> WELL DRILLERS REPORT of the well and notify them before putting.-the- well in.use.. The above <br /> information is true to he-best-of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR 1KNAL INSPECTION. . , <br /> SIGNE TITLE, -- <br /> ,. -- DRAW PLOT PLAN,-ON REVERSE:,�SIDE w <br /> ;FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2- -3`7 <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE . INSPECTION- BY DATE / 'J� <br /> i E R 1426 Rev. 1-74 1-74 2M <br />