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-- SAN JOAQUIN LOCAL HEALTH DISTRICT ! t- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 �7 �p <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/*98Ir_1 CENSUS TRACT <br /> Owner's Name V rtyl` r� <br /> Phone 9 <br /> Address12 <br /> City <br /> Contractor's Name , --� � <br /> Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /% RECONDITION /_7 DESTRUCTION / i <br /> PUMP INSTILf <br /> INSTILLATION / PUMP REPAIR / PUMP <br /> Other /% —/ REPLACEMENT /-7 <br />)IS NCE 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 t` <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> 10;7 <br /> Domestic/private Drilled <br /> Domestic Dia. of Well Casing �- <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal —��=¢ <br /> Cathodic Protection Rotary Type of Grout <br /> O - <br /> Disposal yp � � <br /> Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> UMP INSTALLATION: Contractor r <br /> Type of Pump <br /> H.P. u <br />[TMP REPLACEMENT / / State Work Done <br /> JMP .REPAIR: State Work Done <br />;S•TRUCTION OF WELL: Well Diameter ���,��dn�, dure <br /> �'��l" _�� Approximate Depth <br /> Describe Material an '---- <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br />:ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />:LL DRILLERS REPORT of the well and notify them before putting the. well in use. The above <br /> tformation is true to the best of my knowledge and belief. I WILL CALL F R A �GROUT INSPECT <br /> IOR TO GROUTING AND A FINAL INSPECTIO <br /> GNED yU� <br /> (DRAW PL0 AN ON REVERSE SIDE <br /> ASE I <br /> FOR DEP TMENT USE ONLY <br /> PLICATION ACCEPTED BY DATE <br /> DITIONAL COMMENTS: <br /> P SE G OUT INSPECTION PHASF, IIIhVINAL INSPECTION <br /> SPECTION BY DATE 'J INSPECTION BY DATE 7 <br /> E H 1426Rev. -74 , 1/77 2M <br />