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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-�_V-`)0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2f-7Z <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 4lnd/or install the work herein described. This application is made in compliance with San Joaqut: <br /> County Ordinance No. 1862 and the <br /> /Rules and Reguulatio s of the San Joaquin Local Health District. <br /> . OB ADDRESS/LOCATION S �� � r .. " CENSUS TRACT <br /> aner's Name Phone <br /> Address / City <br /> ontractor's Name /��/4/ �(�(�� /� /��/AC� License # Phone L <br /> YPE OF WORK (Check) : NEW WELL 97 DEEPEN / / RECONDITION /-T DESTRUCTION /7 <br /> b PUMP INSTALLATION � PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other L-1 <br /> , ISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES/VV 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 SPECIFICA ONS <br /> ` Industrial Cable Tool D 0 aviation <br /> _ Domestic/private Drilled of Well Casing / { <br /> _ Domestic/public Driven uge of Casing c <br /> Irrigation Gravel Pack Dep Grout Seal % <br /> _ Cathodic Protection Rotary Type of Grou <br /> Disposal Other Other Information <br /> .. Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> r Type of Pump `vi/�i� /L� ' H.P. /.! <br /> " {II <br /> DUMP REPLACEMENT: / / State Work Done <br /> 'PUMP .REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> `,nd the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I willjurnish the San Joaquin Local Health District a <br /> "ELL DRILLERS REPORT of the well and notify them before putting the-well in use. The above <br /> nformation is true to the best of my. knowledge and belief. 1 WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GRO TING AND A FINAL INSPECTIOF. <br /> SIGNEDF. TITLE /}-7t� ,yL.�� <br /> �� DRLIW PIAT PLAN O ERSE SIDE) T ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r/ <br /> TPLICATION ACCEPTED BY DATE <br /> 6 DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTAN PHASE III/FINAL INSPEC ION <br /> NSPECTION BY �- DATE S- l�' ?� INSPECTION BY DATE 277 <br /> F. H 1426 uP<.. 1-74 ._ ., 3/76 2M <br />