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C_ ® Ir, 5AN JOAQUIN LOCAL HEALTH DISTRICT.,, <br /> FOR OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif: <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_�d6 Zia i <br /> j� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l <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 o£' the San Joaquin Local Health District." <br /> JOB ADDRESS/LOCATION !i S 3 3 CENSUS TRACT <br /> Owner's Name <br /> �4 Phone <br /> Address ' d City o <br /> Contractor's Name License # / _,7 :Mone <br /> Ij <br /> I� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ f RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /)C/ PUMP REPAIR / f PUMP REPLACEMENT /_ <br /> Other / f { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS~ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> (� t <br /> Domestic/private I� Drilled Dia. of Well Casing ; <br /> Domestic/public Driven Gauge of Casing � t <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ,I Other Other Information } <br /> Geophysical. I Surface Seal Installed By: <br /> PUMP INSTALLATION- Contractor <br /> 'Type of Pump ee- �9��f'f / H.P <br /> PUMP REPLACEMENT: /,! / State Work Done _ 41. - <br /> II <br /> PUMP 1)el State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> ��- Describe Material and Procedure - <br /> �p <br /> I hereby agree to complykwith 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 of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of ;he well and notify them before putting thewell in use.... The above b <br /> information is true to the best of my -know l geandb ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING ANP A FINAL ION. <br /> SIGNED <br /> (DE.A PP4PrAN ON. R V RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j <br /> APPLICATION ACCEPTED BY �� DATE <br /> ADDITIONAL COMMENTS: ,!I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY DATE. <br /> E H 1426 Rev. • 1-7d <br /> 0777 902M <br />