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C <br /> k °".le <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT S C <br /> EOR.­OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. --�C <br /> Telephone: (209 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77711ZZ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> acid/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 C Phone <br /> Address City <br /> Contractor's Name .License 11 ,3/ Phone s� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES --- PIT PRIVY <br /> SEWAGE DISPO FIELD ---- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL�ia! PUBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v. <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private "r`� Drilled Dia. of Well Casing i�"""'•__� <br /> Domestic/public Driven Gauge of Casing �¢,zjxd- <br /> Irrigation Gravel Pack Depth of Grout Seal Ov1T' <br /> Cathodic Protection Rotary Type of Grout _ `_z 64 g <br /> Disposal Other Other Information �- <br /> -Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4'r <br /> Type of Pump uH.P. " <br /> PUMP REPLACEMENT / / State Work Done <br /> C.Com- <br /> PUMP :REPAIR: 7a �S•� <br /> / / 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 t bpft knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING D A IN I - <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � �8-7 7 , <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUV INSPECTION P S I/FIN INSPECTION <br /> INSPECTION BY ATE / INSPECTION BY DATE Z 2 ?Z-7-7 <br /> E H 1426 Rev. 1-74 1/77 2M <br />