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_• . V1 . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> op. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77���f�4 <br /> . THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) f ,, <br /> Application is hereby made to the+ San Joaquin Local Health District for a, permit toconstruct <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 Sdy� CENSUS TRACT <br /> Owner's Name rL %/ r Phone �� -- 22, V 2 <br /> d�Vl 0 tnI" - city <br /> t y ` <br /> Contractor's Name e AC License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_7 DESTRUCTION j <br /> PUMP INSTALLATION J�F PUMP REPAIR / / PUMP REPLACEMENT f? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERtt <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS u\,. <br /> Industrial Cable Tool Dia. of Well Excavation QN <br /> Domestic/private Drilled Dia. of Well Casing— <br /> Domestic/public <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout U <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /77; State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept Z <br /> Describe Material and Procedure <br /> C <br /> I hereby agree to comply with all laws alYdregulations 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 GR TING AND-r - IN'" " NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE ON PHASE,.-�TII/FIDJAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> j! <br /> 1/77 . 2M 4 <br />