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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: /f4 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> N Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Permit No. 77 9 D P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X77 <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 /> p� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ZkZ2,1 .�I Phone <br /> Address City s' <br /> Contractor's Name Q License ��� ��� Phone <br /> /_/ <br /> TYPE OF WORK (Check) :' NIE'W WELL '/ / DEEPEN /_/ RECONDITION DESTRUCTION /7_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT ; <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ;SEWER- LINESr ' ," PIT PRIM , ' <br /> *SEWAGE-DISPOSAL--FIELD >CESSPOOL/SEEPAGE PIT. ' OTHER�� i <br /> i'- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIG..WELL j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 qq °°�'�r x Gravel"Pack-- Depth�-of'Gr6ut—seal �*. Sc <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal a , 1 Other Other Information <br /> Geophysical Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. <br /> S L <br /> PUMP REP.L•ACEMENT: State Work Done ( j <br /> PUMP .REPAIR: A./ State Work Done <br /> IDES�TRUCTION OF WELL: Well Diameter ',Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyll.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 /> PRIOR TOG UTING AND A F <br /> ATN41ECT ION. <br /> i SIGNED TITLEJ�c <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />,PHASE I ,� � � .� ` t �.` :w � <br />.APPLICATION ACCEPTED BY ' �-� DATE "� =ZZ <br /> ADDITIONAL COMMENTS: IM <br /> PHASE I GROUT INSPECTION P E /FINAL INSPECT N <br /> INSPECTION BY DATE INSPECTION B)Vi DATE <br /> 1777 - _ 2M <br /> k � I <br /> k_ E H 1426 Rev. 1-74. : - <br />