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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> FOE OFFICE USE: <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77--36 4� <br /> THIS PERMIT EXPIRES 1 REAR FROM DATE ISSUED Date Issued At <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 /> `3333 <br /> 0-71- <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION 1-7 <br /> Phone <br /> Owner's Name <br /> 11- 4& <br /> City.:. �® � a <br /> Address <br /> Contractor's Name <br /> U1 p a License # Phone <br /> ' TYPE OF WORK (Check) : NEW WELL DEEPEN_/ / RECONDITION /� DESTRUCTION /? <br /> � W <br /> PUMP REPLACEMENT /7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other! / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL CO— PUBLIC DOMESTIC WELL <br /> NSTRUCTION SPECIFICATIONS ' <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia, of Well Excavation �• .fes I� _ � <br /> i <br /> C <br /> � asng Domestic/private Drilled Dia. of Well <br /> Domestic/public Driven Gauge of Casing �- - <br /> Gravel Pack Depth of Grout Seal { <br /> Irrigation f - <br /> Cathodic Protection � _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: -, <br /> t <br /> F <br /> PUMP INSTALLATION: Contractor _ -- - - H.P. ' <br /> i <br /> Type of Pump <br /> i. PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work 'Done.rt. <br /> DESTRUCTION -OF WELL:,. =Well-Diameter. �- <br /> 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 we11 ''construction. Within FIFTEEN DAYS <br /> I 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'AIN <br /> ! PRIOR TO OUTING AND A FINAL INSPECTION. TITLE cL <br /> •SIGNED <br /> (DRAW PLOT PLAN QN REVERSE SIDE <br /> FOREPARTMENTUSE ONLY <br /> PHASE I ' DATE <br /> } APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: _ PHASE I /FI AL INSPECTI N <br /> PHASE II GROUT I SPECT IQN INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> t� : 1177 . - _2M �. <br />