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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FO_R OFFICE USE. 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- $7a,Cv <br /> 77-// /,0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7,7 <br /> ! (Complete In Triplicate) <br /> Application is Lreby 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/LOCATION � CENSUS TRACT <br /> Owner's Name � C �.s ��✓� Phone d - <br /> Address City . ` <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check} : NEW WELL /jQ\ DEEPEN/ / RECONDITION / / DESTRUCTION /? \ <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> : <br /> PROPERTY LINE/ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF- WELLCONSTRUCTION SPECIFICATIONSNZ <br /> f Industrial , <br /> Cable Too Dia._ <br /> %Well Excavation jo <br /> �^ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal 7AA <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical f Surface Seal Installed B �� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / 'State Work Done <br /> � rte; <br /> i <br /> iDES•TRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and-regulatians of the San Joaquin Local. Health District -� <br /> and the State of' California ,pertaining to or regulatin . Within FIFTEEN DAYS <br /> g well -construction <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 we�l and notify them before putting the .well in use. The above <br /> information is true to th es of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING TION <br /> TITL <br /> SIGNED <br /> DRAW, PLO 'PLAN ON REVERSE SID <br /> � t <br /> FOR DEPARTMENT USE ONLY <br /> F PHASE I <br /> APPLICATION ACCEPTED-BY-- - � """DATE-;� . <br /> v <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHASE TII FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION%.n DATE <br /> M �e <br /> 2M_ <br />