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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: I/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_3 7 td <br /> p, THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l /3-27 <br />�' (Complete In Triplicate) <br /> y'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 />. _�ounty Ordinance No. 1862 and the Rules and Regulatia s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone / :7 'C�/- <br /> Address �/ �J�e� -- -- � City C � <br /> F <br /> Contractor's Name icense # Q Phone �,r, - <br /> r <br /> TYPE OF WORK (Check) : NEW WELL 1;;r DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/—/ PUMP REPLACEMENT /_7 <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 Cable Tool. Dia, of Well Excavation /'_::X- Q' <br /> Domestic/private L__-Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing '_' <br /> Irrigation Gravel Pack Depth of Grout Seal ,� O <br /> Cathodic Protection __ Rotary Type of Grout <br /> Disposal Other Other Information L, <br /> Geophysical Surface Seal Installed B :�; ��� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -' s "fff +�'".,rte Approximate Depth <br /> Describe Material and Pro dure <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 dlq <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIAN" <br /> PRIOR TO G OUTING ANDA F NAL INS Ci}I N. <br /> SIGNED 6�. (TITLE . <br /> DRAW ZIT F AN ON RE SE SIDE) r 1 =: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I O <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS <br /> PHAS ' II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION B DATE INSPECTION B DATE <br /> E H 14263�7 <br /> Rev. 1-74 <br />