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j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-t�3S r° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f -2a_ <br /> F rI (Complete. In Triplicate) <br /> Appliddtion is' hereby made t'o 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 /> C6unty Ordinance No. 1862 and the Rules and Regulations of the Sa aquin.,Local Health District. <br /> 7 <br /> i JOB ADDRESS/LOCATION - CENSUS TRACT <br /> 1 <br /> Owner°s Name .v Phone <br /> Address w ar'� <br /> City <br /> Contractor's Name License # .91al"Y Phone �--q <br /> TYPE OF WORK (Check) NEW WELL -/-7 DEEPEN '/7 RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /� .PUMP REPLACEMENT <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 v <br /> Domestic/private Drilled Dia. of Well Casing <br /> f Domestic/public Driven Gauge of Casing \ <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 r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> ti PUMP '.REPAIR: /7 State Work Done <br /> ,SES 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 the-best-of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIU AND A FINAL INSPECTION. <br /> SIGNED �.. TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 3 oo" <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E III NAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ' 1-74 2M <br />