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SAN JOAQUIN ZOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77_3�e2 lv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �5--Y'- 7� <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 Q�� S /7 Uj T`r OSI CENSUS TRACT <br /> Owner s Name SIV ( Phone <br /> Address 307 City <br /> Contractor's Name License # Phone <br /> . i <br /> TYPE OF WORK (Check) : NEW WELL &I-T DEEPEN/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTILLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial `, Cable Tool Dia. of Well Excavation �. <br /> Dr;tic/pr4vate Drilled Dia. of Well CasingDt�i�' x�b1, Driven Gauge of Casing VJ <br /> Irrigation` "`� Gravel Pack Depth of Grout Seal <br /> Other -^ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor-------- <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> i <br /> PUMP '�ZPAIR: / / Mate Work Done <br />,DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws- and regulai�ians 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 /> informat' n is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �- <br /> " FOR DEPARTtIENT,USE ONLY <br /> PiASE I <br /> APPLICATION ACCEPTED BY � DATE .^ <br /> .� �-- .. <br /> ADD ITIOaAL'COMMENTS <br /> INSPECT _4K <br /> INSPECTION BYDATE � INSPECTI DATE l <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />