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SAN JOAQUIN-:LOCAL 'HEALTH DISTRICT <br /> FORI'OFFICE USE: 1601 E. Hazelton'AVe.:.; 's5tockton, Calif. # <br /> Telephone: (209)•`466-6781 CD4_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77•^ <br /> T 7-2-910 <br /> THIS PERMIT EXPIRES 1'-.;YEAR FROM DATE ISSUED Date Issued7�; (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.... Thio,,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 /> JOB ADDRESS/LOCATION, .` . l CENSUS TRACT <br /> Owners Name Phone <br /> Addres's' ' r City �- l <br /> Contractor's Name r License _%EPhone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT r7a <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK.,- y 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 <br /> 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 N r <br /> 3C Irrigation Gravel Pack Depth of Grout Seal <br /> i Cathodic 'Protection- Rotaryx�A <br /> � -Type of Grout- � � <br /> Disposal Other f Other Information f <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: 1_7 State.,Work Done <br /> ES•TRUCTION OF WELL: Well-Diameter f 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 RE of the well and notify them before putting..the..wel.1 in.use.. The above <br /> information is t(rue) arRhe st o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT ; • FIN PECTION. <br /> SIGNED TITLE <br /> "=Mal W PLOT PLAN ON REVERSE SIDE <br /> FOR . EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 11,31-7-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA§ Ig/FYNAL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />