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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77 73'� <br /> 5(-D THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X77 <br /> v (Complete In Triplicate) <br /> Application is Aereby 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 :z CENSUS TRACT <br /> Owner's Name Phone -- ,/Q <br /> Address City ;` , <br /> Contractor's Name y License It-f Phone / <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <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 kA <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 <br /> Disposal Other Other Information -� <br /> Geophysical Surface Seal Installed By: <br /> Ar- <br /> PUMP <br /> rPUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ,.REPAIR: / / 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 the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OU ING AND A FINAL SP CTIO . , <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> F DEPARTMENT USE ONLY / <br /> PHASE I / t <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: v r <br /> PHASE II GROUT INSPECTION PHAS <br /> 4 II 'FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY;' DATE <br /> E H 1426 Rev. 1-74 11Z7. 2M <br />