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' yy <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �P <br /> FOR 0 FICE USE 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7 <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.-1 <br /> ibed. This application is made in compliance with San Joaquin <br /> County Ordinance No1562 2 and. the Rules �,R ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT ON Gownq x'1/0 CENSUS TRACT <br /> Owner's Name r�} Phone <br /> Address ff. A/ <br /> City � . <br /> Contractor's Name <br /> E License # (0t#734 Phone ��,-��„`7�\ I <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN / / RECONDITION / / DESTRUCTION /_s <br /> PUMP INSTALLATION / / PUMP REPAIR /x/ `PUMP REPLACEMENT / <br /> Other / / # <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT : OTHER ` ' I� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL �-�] � <br /> TNTENDED USE TYPE OF WELL CONSTRUCTION SPECTFICATTONS <br /> Industrial Cable Tool Dia, of Well Excavation. <br /> Domestic/private Drilled <br />� Dia, of Well Casing <br /> � Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical , Surface. Seal, Installed By: <br /> ' I <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump f, H.F. <br /> PUMP REPLACEMENT } <br /> / / State Work Done - <br /> S \IPUMP .REPAIR: /�C/ State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth I <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> BELL DRILLERS REPORT -of the well and notify them -before putting the' well.'in use.. The above <br /> Lnformation is true .to the best of. my knowledge an?i belief.. I.WLLL CALL''FOR A"GROUT .INSPECT30N <br /> RIOR TO GROUTING AND A FINAL INSPE IO <br />;TGNED TITLE <br /> D W PLOT PLAN ON VERSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br />'RASE I <br /> APPLICATION ACCEPTED BY <br />,DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION P S IY /FINAL INSPE TION <br />.NSPECTION BY DATE INSPECTION BY DATE <br /> __E ,H-1.26 Rev'. 1-74 _ � 1x`77 _" 2M 1 <br />