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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi,OFFICE USE: 1601 E. Hazelton Ave. ,+ S_tockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '_s7U uJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F-17- <br /> (Complete <br /> -/77(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 A&09 N <br /> OG �J S 1� <br /> v <br /> �. { CENSUS TRACT <br /> Owner's Name p Phone 776 -/,/7 <br /> Address ! Q <br /> Contractor's Name . . <br /> License #e2Phone ,�f.�3f- <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN ��/ RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR/� PUMP REPLACEMENT /7 <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK ros SEWER LINES ZZ PIT PRIVY + <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLICDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' f ` ' . • CONSTRUCTION SPECIFICATIONS <br /> dstrial able Tool Dia. of Well Excavation Vi <br /> Domestic/private Drilled j -Dia...of Well Casing .f <br /> Domestic/public Driven ` Gauge of,Gasing <br /> Irrigation Gravel Pack Depth of`Grout Seal + <br /> Cathodic Protection Rotary �� Type of Grout <br /> Disposal - OtherInformation ' ' <br /> - Other <br /> Geophysical Surface Seal Installed 'B <br /> } <br /> PUMP INSTALLATION: Contractorx `4 <br /> �i <br /> Type of Pump �- - <br /> H.P. <br /> s <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done <br /> RES'TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> ;t <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 />'RIOR TO GROUTING AND INAL INSPE ON. <br /> SIGNED r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) .°.`. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , s <br /> 4PP ATZON ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: # <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY e `,C(, :. DATE <br /> E H 1426 ~ r <br /> Rev. 1-74 i' � t./ter nu <br />