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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE`IOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- <br /> .1300 <br /> -,. <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 Sari Joaquin Local Health District,. <br /> JOB ADDRESS/LOCATION ��Cf CENSUS TRACT <br /> Owner's NamPhone <br /> Address City01 <br /> Contractor'fi Name License ) Phone <br /> , TYPE OF WORK (Check) : NEW WELL /? DEEPEN '/_7 RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION 10 PUNP REPAIR / / Pump REPLACEMENT /-]• <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPQSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 3 PROPERTY LINE PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS ...•n • <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 _ (� <br /> Cathodic Protection Rotary Type of Grout S\ <br /> Disposal Other Other Information �1 <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: / / State Work Done <br /> DES€RUCTION, OFW_ELL: 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 FIFTBBN 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 abo've .. <br /> information is true to the-best of my knowledge and belief. I, WILL CALL FOR A GROUT IN3PECTI(�i, <br /> PRIOR TO GROUTING MD A FINAL INSPECTION. <br /> SIGNED TITLE <br /> %R W PLAN 'ON ESE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY `' DATE G LI <br /> I <br /> ADDITIONAL COMMENTS: <br /> ..PHASE II GROUT INSPECTION PHASE AIX FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 DATE <br /> E H 1426 Rev. 1-74 �� .6 <br />