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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �} <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r77-Y/-/L/t' <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 /> 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 G o'�G J _D-0 CENSUS TRACT <br /> Owner's Name Phone <br /> Address ® 'o City <br /> �i <br /> i <br /> Contractor's Name � License #-�WIOPhone F3FeEl <br /> 4 <br /> i� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 y` Cable Tool Dia. of Well Excavation 0 <br /> Domestic/private` Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation � # i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: ContractorOL <br /> -Type of, Pump - .. --__ H.P.- <br /> t' ��Q <br /> PUMP REPLACEMENT: / / State Work Done�Q �drt - <br /> PUMP .REPAIR: ; / / State Work Done <br />,DES<TRUCTION 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 DRILLERSdREPORT of the well and notify them before putting the wellin use. The above <br /> information is. true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f / _ DATE -13--7-7 <br /> ADDITIONAL COMMENTS: <br /> : PHASE II GROUT INSPECTION PHASE 4,7/FINA4 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE :Z-/ -77,7 <br /> 117T , . 2M <br /> R N T L?A D.- 1_71, <br />