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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: (v),6 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z 7 JO )d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued gLZ.Z� 77 <br /> (Complete In Triplicate) <br /> Application is h reby 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 . " CENSUS TRACT <br /> Owner's Name PhoneA 9^3 <br /> Address 1 / 3y 10 City <br /> Contractor's Name �'�o/ rte/ License 4 Aoa373 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION -7 DESTRUCTION /- <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing f\" <br /> Irrigation Gravel Pack Depth of Grout Seal W <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical nSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor V <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ r <br /> PUMP .REPAIR: State Work Done <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 thewellin use. The above <br /> information is true to the best of mynowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A FI INSPE N. <br /> SIGNED TITLE <br /> W PLAN 'ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C- DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /',Q DATE i • 77 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />