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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79- I/W <br /> ------------ <br /> k THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> I Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> i and/or install the work herein described., This application is made in compliance with San Joaquin <br /> I County Ordinance No. 1862 and the Rules and R ulations n£ the San Joaquin Local Health District. <br />` JOB ADDRESS/LOCATION O <br /> CENSUS TRACT . <br /> Owner's Name - <br /> Phone �� a�j <br /> Address City � <br /> Contractor's Name ? License Phone <br /> • a <br /> f TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY D <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _�j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial C Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing „ n <br /> Domestic/public Driven Gauge of Casing V1 <br /> Irrigation Gravel 'Pack Depth of Grout Seal G <br /> Cathodic Protection Rotary Type of Grout <br /> .Disposal Other Other Information <br /> Geophysical Surface Seal Installed B - _ - <br /> PUMP INSTALLATION: ^ Contractor <br /> Type of Pump H.P.- <br /> PUMP REPLACEMENT: /1177 State Work Done e <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 1 <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 GROUTING AN FINAL INSPE ION. <br /> SIGNED TITLE �L ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FORDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE �7-- <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPE ON PHAS II/FNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE —7 <br /> E H 1426 R,. . 1_7A " 0/77 �� <br />