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SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209)' 466-6781 <br /> : APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77-A�if_ <br /> .•, THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 117 <br /> X (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. 1 62 and the Rules a dRe u�lpati of tthhee an Joa uin Local Health District. <br /> JOB ADDRESS/LOCATION �] CT <br /> Owner's Name Phone <br /> Address, City <br /> Contractor's Name License It � Phone 3 �� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL. /DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> REPLACEMENT <br /> NEW <br /> INSTALLATION / / PUMP REPAIR I�T <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 h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation=A <br /> Domestic/private , Drilled ..„.Dia.... _of pWel1,Casing, <br /> _ - <br /> Domestic/public Driven Gauge of Casing <br /> _ 1.,—Irrigation a Gravel Pack Depth of Grout Seal <br /> Cathodic Frbtection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY : <br />` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUM!' REPLACEMENT: / / State Work Done <br /> F ' <br /> PUMP •REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t Approximate Depth <br /> Describe Material. and Procedure <br /> 1, I hereby agree to comply with all laws and-regulations of theSanJoaquin Local Health District <br /> and the State of California pertaining to of 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 Q,40UTING AND A FINAL INSPECTION. <br /> TITLE <br /> , SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> F FOR DEPARTMENT USE ONLY <br /> PHASE I _Q �� ,2 7 <br /> 1APPLICATION ACCEPTED BY T DATE � , <br /> • ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> JI <br /> E INSPECTION BY DATE INSPECTION BY �",��. ' DATE 11- F' <br /> ; 1/77 214 <br />