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F JOAQUIN LOCAL HEALTH DISTRICIn <br /> ?OR OFFICE USE: ' 160.- Hazelton Ave. , ,Stockton, Cal_. . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-& <br /> .; THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> -O plication is hereby made to' the San Joaquin Local Health District for a permit to construct <br /> id/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 /> )B ADDRESS/LOCATION / rAr CENSUS TRACT <br /> �. <br /> Owner's Name Phone <br /> P41 <br /> :;.ldress City <br /> `r'pntractor's NameAWL` License 'hone " <br /> T-jPE OF WORK (Check) : NEW WELL/DEEPEN %/ RECONDITION / / DESTRUCTION /-7 <br /> � k PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> ] 7STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> 'r rI Domestic/public Driven Gauge of Casing <br /> � ,' j/'Irrigation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection Rotary Type of Grout <br /> '._r-.—Disposal Other Other Information <br /> M � Geophysical Surface Seal Installed B <br /> PIMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> F \ <br /> L...MP .REPAIR: / / State Work Done <br /> rS•TRUCTION OF WELL: Well Diameter . . Approximate Depth <br /> Describe Material and Procedure <br /> L-hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> C' 'd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> aL�ter 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 /> 4-LOR TO ROUTING D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 1, PHASE I <br /> A' PLICATION ACCEPTED BY l/�J DATE <br /> 4� EDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE VI/FINAL INSPECTION <br /> LnLSPECTION BY DATE INSPECTION BY DnkTE 71 <br /> E H' 1426 Rev. 1-74 <br />