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SAN JOAQUIN LOdA; HEALTH DISTRICT ' <br /> FOHOFFICE USE: '`" 1601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77110 <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,?-.4 1 <br /> (Complete In. Triplicate) I <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 /> JOB ADDRESS/LOCATION ;V&,,t r CENSUS TRACT <br /> Owner's Name 1z 7 Phone <br /> Address S - City <br /> Contractor's Name S✓ License # 2Nozp Phone alt-c.)4d�7 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /7 RECONDITION _7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR I I PUMP REP CEMENT 17 <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE W PRIVATE DOMESTIC WELL PUBLIC_DOMESTIC WELL <br /> Industrial USE <br /> TYPE OL <br /> rialCableTool Dia. of WeSPECIFICATIONS <br /> Well Excavation <br /> � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ,Gauge of Casing i <br /> Irrigation Gravel Pack µDepth -of Grout Seal <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 H.P. <br /> e <br /> PUMP REPLACEMENT: / / State Work Done <br />`^PUMP !REPAIR: —S t-a te' Work Done t _ <br /> &ES-7RUCTION OF WELL: Well Diameter Approximate Depth <br /> W 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 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 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 /> PRIOR TO GROI G AND FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEO <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3AZZ;2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP TION PHASE IIIIRINAL INSPECTION <br /> INSPECTION BY4aADATE INSPECTION BY/F DATE <br /> 1 E R 1426 Rev. 1-74 1_7A 9M <br />