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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ,J-' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 77 lel-�-/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8_// <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,b98�'ON a (! 17� df CENSUS TRACT <br /> Owner's Name /(�' � '1�pOS'zat_ Phone <br /> Address City <br /> r <br /> Contractor's Name r,,$�B'f License ���Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/,V DEEPEN / / RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ PUMP REPAIR/ / PUMP REPLACEMENT /_7Other / / W <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES Cj �- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT / OTHER <br /> PROPERTY LINE-TPDOMESTIC WELL �4"PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> XDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal e� - <br /> Cathodic Protection Rotary Type of Grout �t <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: /7 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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED _,UTLE <br /> D t L ON REVERSE SIDE) <br /> FOR DEP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /9DATE <br /> ADDITIONAL COMMENTS: t o <br /> PHASE II GR UT INSPECTIO P E II /F NAL INSPECTION <br /> INSPECTION BYDATE ly IZ-7;2INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 376 2M <br />