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r S)JOAQUIN LOCAL HEALTH DISTRICT <br /> Stockton Calif. <br /> : FOA+O CE USE: 1601 E. Hazelton Avi <br /> Telephone: (209) 466-6781 <br /> ij APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 77-/ <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) I; <br /> Application is hereby made to the San Joaquin Local' Health District for a permit to construct <br /> and/or install thel�work' herein described. This application is made in compliance with San Joagn3. <br /> County Ordinance NO. 1862 and the Rules and Regulations of the San Joa <br /> 11, District. <br /> JOB ADDRESS/LOCATION �. N CENSUS TRACT <br /> .owner's Name Phone <br /> II City C ,q <br /> 5" <br /> Wdress � <br /> i ,ontractor's Name;, ti <br /> License #.2240laPhone <br /> TXPE OF WORK (Check) : <br /> NEW WELL /7 DEEPEN /7 RECONDITIDJ1° uI � <br /> .,PUMP INSTALLATION PUMP REPAIR p1ZMP�R�EPLAC T �h <br /> .10ther <br /> TISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL N <br /> INTENDED USE ;, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j; Cable Tool Dia. of Well Excavation <br /> Domestic/private` Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i; j Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> ?UMP INSTALLATION: 'i Contractor <br /> Type of- Pump g'P' 4p <br /> PUMP REPLACEMENT: State Work Done <br /> �i / / . <br /> PUMP :REPAIR: State Work Done - <br /> 7ES•TRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Materia]. 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:� ofmy 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 FORA GROUT INSPECTION <br /> 'RIOR TO GROUTING ANDA KNINSPECTION. - <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �s FOR DEPARTMENT USE ONLY <br /> PHASE I ;� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I� <br /> 1, PHASE JI GROUT SPECTION PHAS I/A, NAL INSPECT;ON <br /> INSPECTION BY :I DATE INSPECTION BY DATE <br /> R W 1 L?A unit 7_7/i __ <br />