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SAN JOAQUINr LOCAL'HEALTH DISTRICT <br /> FOfi3OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 s6SrrJ <br /> 77- <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/EOCX!'Y'O1Q- CENSUS TRACT <br /> Owner's Nance <br /> ��- i`< Phone <br /> Address <br /> `.- City <br /> Contractor's Name License Z Phone '/- 7 <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN -/_7 RECONDITION /7 DESTRUCTION r7 <br /> PUMP INSTALLATION PUMP REPAIR 1-7-PUMP REPLACEMENT 17 <br /> Other j/% . <br /> DISTANCE TO-NEAREST: - SEPTIC TANK SEWER LINES ,_ - PIT PRIVY <br /> SEWAGE DISPOS FIELD — CESSPOOL/SEEPAGE PIT j p THER <br /> PROPERTY LINA PRIVATE DOMESTIC WELL, 'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> `X Domestic/private X Drilled Dia: of Well Casing <br /> Domestic/public �`i Driven Gauge of Casing <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 By: <br /> PUMP INSTALLATION: r <br /> Contractor <br /> Type of Pump i r` H.P. <br /> PUMP REPLACEMENT: E7 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 i <br /> information is true to the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION I <br /> PRIOR TO GROUTING AND A ,FINAL INSPECTIO <br /> SIGNED �R <br /> DRAW PW7 PLAN—ON REVERSE SIDE <br /> PHASE I FOR DE ARTMENT USE ONLY + <br /> APPLICATION ACCEPTED BY DATE lr <br /> ADDITIONAL COMMENTS: 7;z i <br /> PHASE II GROUT INSPECTIONPRASE I I NAL INSPECTIO <br /> INSPECTION BY — DATE 317-2 INSPECTION BY DATE �f <br /> E H 1426 Rev. 1-74 <br />