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_ SAN JOAQUINzLOCAL HEALTH DISTRICT <br /> FDR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> "' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77- W7/9 <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( J CENSUS TRACT <br /> t <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractox's Name C-J License # •JZ Phone "59 <br /> 3 4 <br /> TYPE OF WORK (Check) : NEW WELL /_/., DEEPEN :/_/. _RECONDITION -/-7,DESTRUCTI0N­/7T--- <br /> PUMP INSTALLATION /.. / '• PUMP REPAIR /q PUMP REPLACEMENT /7 <br /> Other /. // <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT,PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT.� OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE -OF WELL CONSTRUCTION SPECIFICATIONS <br />' Industrial , Cable Tool Dia:,of Well Excavation <br /> Domestic/privatek Drilled Dia.`of- Weil Casing <br /> Domestic/public'-{' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 'RUMP INSTALLATION: Contractor ��✓-� T { <br /> Type of Pump H.P. 7 <br /> PUMP REPLACEMENT: / / State Work Donee <br /> PUMP ,REPAIR: / / - State,Work Done <br /> DESTRUCTION OF WELL: Well;Diameter Approximate Depth <br /> Pte-- Describe Material and Procedure <br /> G <br /> f I hereby-agree- to comply with all-lawg-arid-tegulatzions of the San-Joaquin Ldcal health District <br /> and_ the State of .California pertaining_to-or..-regulating�well ••construction. Within .FIFTEEN•-DA .S <br /> after completion of my worO 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 toftheibest of my knowledge and belief. I WILL CAA FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN A NAL INSPECTION. <br /> SIGNED Ce ; TITLE �� ._._. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> f <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> fi <br />! APPLICATION ACCEPTED BY DATE 3 7 <br /> ADDITIONAL COMMENTS: <br /> `PHASE II G T INSPECTION PHASE IN NSPECTION <br /> . INSPECTION/By / DATE INSPECTION BY ATEA -?d <br /> 12w <br /> E H 1426 Rev. 1-74' ' 1177 - PM <br />