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ti <br /> _ -5 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FGr_ 17 USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-6c,!!/Wl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 77 <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. I <br /> JOB ADDRESS/LOCATIONYfCENSUS TRACT <br /> 4 - 1�4 .//Q� <br /> �-- Wt.z <br /> Owner's Name q/ Phone <br /> Address ., City <br /> Contractor's Name h <br /> License # Phone ^�Z Q J <br /> TYPE OF WORK (Check) : NEW WELL &/- DEEPEN / / RECONDITION / / DESTRUCTION �- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 9 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />'- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 6 ND <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> f <br /> Cathodic Protection x Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : — OO <br /> PUMP INSTALLATION: Contractor <br /> -„ Type of Pump H•P <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP .REPAIR: <br /> / / State Work Done <br /> i <br /> i <br /> DESJRUCTION OF WELL: Well Diameter 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 /> ani the State of California pertaining to or regulating well 'cons truction. 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 />'RIOR TO CEO <br /> UTIN NAL INSPECTION. <br /> SIGNED TITLE _ <br /> ,. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE XPi 477 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S /FTN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> a <br /> `E H 1426 Rev. 1-74 <br />