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- / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. SCANNED <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 yfSV <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��S�� �QG Oj �� CENSUS TRACT <br /> Owner's Name rte, /�f �� Phone <br /> Address �j 7X /L4fYC City <br /> Contractor's Name awA/z . /y j/� /LU.cfl> License #2,SjVgS 7 Phone <br /> TYPE O%1KORK (Check) : NEW WELL /VJ DEEPEN / / RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER CA <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 / <br /> pC� Domestic/private Drilled Dia. of Well Casing �;3 i,t/ <br /> Domestic/public Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack Depth of Grout Seal T, <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: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> m <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 GR UTING AND A FINAL IN PE CT ION. <br /> SIGNED! - TITLE <br /> (DRAW PLOT PLAN SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY ( - �a�i/V DATE S L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /°, DATE ( 2�/l J <br /> 376 2M <br /> E H 1426 Rev. 1-74 <br />