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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 /> 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/LOCATIONzw� t�J CENSUS TRACT <br /> Owner's Name I - Phone <br /> Address �-3�'j" S City s��U <br /> Contractor's Name License #/f3724- Phone 4j, - 4 <br /> c i <br /> I <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /% RECONDITION /—/ DESTRUCTION /_J <br /> PUMP INSTALLATION / / PUMP REPAIR/X/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal rn <br /> Cathodic Protection Rotary Type of Grout I <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: /% State Work Done - <br /> PUMP REPAIR: / State Work Done r.�ttinm {7 + p�jj 7J 9-NAk <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 kn ledge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS 0 <br /> SIGNE ¢ - TITLEj�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE2�._�, <br /> TIONAL COMMENTS: <br /> PHASE II : O IN09CTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY TE" INSPECTION BY DATE o2 8JI <br /> E H 1426 Rev. 1-74 3/76 2M <br />