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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR. OFFICE US 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Periiit No. 77- <br /> 401 <br /> t► <br /> -M- - 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 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 Districts <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> 4" Phone <br /> Address <br /> City <br /> Contractor's Name -"'�"�� <br /> License #/�--pFione ' <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN /_7 RECONDITION /7 DESTRUCTION /"7 <br /> AL <br /> PUMP INSTLATION /—/ PUMP REPAIR 4PPUMP REPLACEMENT <br /> Other /? <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL�'- <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />�V Domegstic/private Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal . <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump OV <br /> t�� �1 <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done I.- <br /> DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health bistrict <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 r <br /> 4ELL 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 wledge and elief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO G T G AND A FINAL INSPE I� <br /> iIGNED TLEy- ,j� <br /> {D W LOT P ON REV RSE SIDE) <br />,RASE I OR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED BY DATE �� <br />►DDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> J <br /> s <br /> I <br /> E H 1426 `Rev. 1-74 1177 2M i <br />