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- <br /> SAN JOAQUIN LOCAL BEALTH DISTRICT <br /> FOF,OFFICE .USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- ,; 3Tzd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 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 /> County Ordinance. No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONPzo <br /> CENSUS TRACT <br /> Owner's Name �,,L�.- Phone <br /> Address Gd City -� <br /> Contractor's Name C, License # Phone `7j�Z- 7 <br /> 3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/7/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /_/ PUMP. REEAIR I I PUMP REPLACEMENT /-7 <br /> Other / / <br /> ._ —Q <br /> 4 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 /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 11 -1 <br /> Cable Tool Dia. of Well Excavation A9r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 12, <br /> Irrigation i Gravel. Pack Depth of Grout Seal 6-1/9 . <br /> Cathodic Protection r y Rotary Type of Grout- <br /> Disposal Other Other Information <br /> Geophysical - Surface Seal Installed By: - _-. - <br /> PUMP INSTALLATION: Contractor <br /> y/Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />•I PUMP •.REPAIR: / / State Work Done <br /> l� DES-IrRUCTION 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 o2my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INS CTION. <br /> SI•GNED�._: �yUc�•Z,,7r,I -.TITLE - <br /> (DRAW PLOT PLAN ON�REVERSE SIDE) <br /> G FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - 0-�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PIASUIVI/FINAL INSPECTION <br /> . SPECTION BY DATE .. INSPECTION BY DATE 1®- <br /> Ci <br /> ,t 1426 Rev. 1-74 1177 X) <br />