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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 FOR OF ICE USE: 1601 E. Hazelton Ave. , ' Stockton, Calif. <br /> Telephone : (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 77-5721 <br /> THIS PERMIT EXPIR �' <br /> ES 1 YEAR FROM DATE ISSUED Date Issued � 77 <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 thea}les and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSLOCATION �Q��y�7 -� <br /> l �0A.c�° �Grorr A4 t-v" rn ,4- ,VO CENSUS TRACT <br /> Owner's Name /Vt [a j/ 1/ Phone <br /> i - <br /> Address A .i ! city <br /> j c <br /> f Contractor's Name Qs License # 3 ,urPhone. J66 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ /. RECONDITION /_/ DESTRUCTION /_ <br /> PUMP .INSTALLATION / / PUMP REPAIR /Se/ PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIFE – PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ' Dia. of Well Excavation <br /> I ..- _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing .. <br /> IrrigationGravel Pack Depth' f ,Grout Seal <br /> _ <br /> Cathodic Protection"-'-" �'_..."'"" � Rotary _ Type of Grout `, - '.J <br /> Disposal Other S Other Information <br /> Geophysical. Surface Seal Installed By : <br /> i PUMP INSTALLATION: Contractor � 44_.4 <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 elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NINQ AND,A FINAL INSPECTION <br /> SIGNED Cp ` ITLE � �� <br /> (D P T PLAN ON ifffERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I Q <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II OUTINSPECTION PHASE I/ INAL INSPEC I N <br /> INSPECTION BY � DATE INSPECTION BY DATE <br />