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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR-OFFICE USE: ' 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466--6781 �;7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7-// <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-d6-27 <br /> (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 Dist4ct. <br /> JOB ADDRESS/LOCATION - /�f �j CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name, License Phone <br /> TYPE OF WORK (Check) : NEW WELL/Z7 DEEPEN /_/ RECONDITION / / DESTRUCTION // <br /> - PUMP INSTALLATION //- PUMP REPAIR / / PUMP REPLACEMENT // 4 <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 L--Cable-Tool; Dia. of Well Excavation \v <br /> Domestic/private Drilled Dia. of Well' Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack - Depth of Grout Seal ' <br /> Cathodic Protection Rotaryr Type. of Grout 91 <br /> Disposal Other Other Information <br /> GeophysicalSurface Seal Installed By: <br /> PUMP 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 GROU;ING.AND A FINAL INSPECT ON <br /> SIGNED TITLE <br /> '-( RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TI GROUT INSPECTION PHASE I_ II/FINAL INSPECTION <br /> INSPECTION BY DATE ? INSPECTION BY E/ DATE 11 -77 <br /> E H 1426 Rev. 1-74 ' I/77- 2M <br />