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SAN JOAQUIN LOCAL HEALTH. DISTRICT 0 v yy <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. 77n4;0 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued/0-/3'7 <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/LOCATION CENSUS TRACT <br /> Owner's Name- Phone <br /> h <br /> Address City <br /> ntractor's Name _ ,� .� ` -cense Phone f, <br /> PE OF WORK (Check) : NEW WELL /t —"DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /G1'PUMP REPAIR /-7/,—PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ele _ SEWER LINES PIT PRIVY ,, 1v <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE1,PIT 4 OTHER <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC �DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � . <br /> Industrial 4---'Cable Tool Dia. of-Wel—,Excavation <br /> L --fomestic/private Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing Z42 _ 1 <br /> I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type` of Grout <br /> Disposal Other Other Information <br /> .'Geophysical Surface Seal Installed By147/W : <br /> PUMPINSTALLATION: Contractorj - _�►t <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 belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ^ ION <br /> SIGNED <br /> TITLE <br /> R T N D A FINAL INSPECT' ..._ -- ---- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE LJ /3 <br /> ADDITIONAL COMMENTS: <br /> PHAS T tROUT INSPECTION PHASE UF AL CTN4 <br /> N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - /, -a ' <br /> �177: w ° ate <br /> ti r- �. <br />