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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFRICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-3 73� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <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 LOCATION ADDRESS �a �ro 7 ' <br /> / __ ,S'� ����, ca F§ �v hrrr' .v"t lig cwc,.,.�~f ; rj e`�,;,,�w CENSUS TRACT <br /> Owner's Name - Phone <br /> f <br /> Address p;"' "` -, , ' + r' `. «:- e J City .. . <br /> Contractor's Name License # / ,"; Phone .. , <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION REPAIR /1�C/ 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing \ <br /> Irrigation Gravel Pack Depth of Grout Seal �l <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: \ <br /> PUMP INSTALLATION: Contractor r <f <br /> Type of Pump '` H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done 2, . ' fu ,- °�' 1 <br /> DESTRUCTION 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 GROU ING AND A FINAL INSPECTION, <br /> SIGNED I-T, ' �» TITLE ' ,y <br /> (DRAW PLOT PLAN ONtREVKRSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �- DATE <br /> APPLICATION ACCEPTED BY t1. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION PHASE III/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' }� <br /> 66177 <br /> - 2M <br /> E H 1426 Rev. 1-74 <br />