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" SAN JOAQUIN LOCAL HEALTH DISTRICT FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.Telephone : (209) 466-6781 Vet <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT No. 77-3,5-1_1' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1-,7- <br /> Application is hereby ( <br /> eTriplicate) <br /> t <br /> made to the San JoaquinLocalHealthDistrict for a permit to construct <br /> and/or install the workherein, described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 182 and the Rules and Regulations of the San Joaquin Local al Health District. <br /> JOB ADDRESS/LOCATION Z17 �3 CENSUS T <br /> RACT <br /> Owner's Name I' Phone <br /> i <br /> Address _ <br /> City <br /> Contractor's Name r <br /> �� �-� cLicense ak—a� Phone <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN /_% RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT' <br /> Other — <br /> ' I ' <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY; y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE P,IT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL �} <br /> INTENDED USE TYPE OF WELL CONSTRUCTION/SPECIFICATIONS (� <br /> Industrial Cab 1e Tool Dia." of Well-Excavation (� <br /> Domestic/private Drilled Dia, of-Well Casing <br /> Domestic/public Driven <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth. ofyGrout Seal <br /> Cathodic Protection Rotary --,,-Type of Grout <br /> Disposal <br /> Other ' Other Information <br /> Geophysical �,-�" <br /> ��r'" Surface Seal installed B : ' <br /> d ..� <br /> PUMP INSTALLATION: -C©ntracto <br /> Type of Pump .. _�.. H.P. r <br /> PUMP REPLACEMENT- J / State Work Done r <br /> PUMP .REPAIR: /111 J State Work Done <br /> DESTRUCTION OF WELL: Well Diameter` Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply$ ith 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 tle best. of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION I <br /> PRIOR TOG OUTING AN A FINAL_ INSPECTION. I <br /> SIGNED TITLE { <br /> JM s (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR PART T USE ONLY <br /> ._.. , <br /> APPLICATION ACCEPTED BY a' DATE <br /> ADDITIONAL COMMENTS: V, E <br /> PHASE I GRQiJT INSPECTION PHAS I/ A14INSPECTIO <br /> INSPECTION BY 11, DATE INSPECTION BY DATE <br /> H 426= Rev. 1-74 j�� t y_ 1177 -. 2M <br />