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F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Foo iOFFw ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781, <br /> APP, CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 d6kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED Date Issued Z=2 <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 theeQRules gnd Regulations o he San Joaquin Local Health District. <br /> v <br /> JOB ADDRESS/LO ON CENSUS TRACT ; <br /> Owner's Name " Phone �2p� <br /> Address. Cit <br /> Contractor's Name z .. U _ Licenseho <br /> � _ <br /> "tYP$'OF WORK (Check); NEW WELL ) DEEPEN F RECONDITIONi/7 DESTRUCTION rT <br /> PUMP INSTALLATION / / 'PUMP REPAIR / / PUMP REPLACEMENT, .° <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 0EWER LINES PIT PRIVY &,. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT `OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC'WELL PU$LIC DOMESTIC WELL <br /> } <br /> INTENDED...USE TYPE OF WELL CONSTRUCTION SPECIFI A IONS <br /> iTiidustrial- _ - Cable Tool Dia: of Well Excavation - \e <br /> Domestic/private Drilled Dia'. of Well Casing <br /> Domestic/public Driven Gauge of Casing ! r <br /> Irrigation Gravel`_;Pack ' Depth of Grout Seal * ` <br />�. Cathodic Protection Y Rotary Type�-of Grout <br /> r Disposal. Other Other Information <br /> Geophysical. Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor �z <br /> k4 Type of Pump H.P. <br /> PUMP REPLACEMENT: / "State Work Done <br /> r—PUMP_`9EPAIR-°—`a - <br /> I.� <br /> ,PES�TRUCTION OF WELL: Well Diameter r ` 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 /> and the Slate 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 ruse..: The above <br /> information is true to the-best of- my knowledge and belief. I WILL CALL FOR A`GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTION. , * 4� <br /> �. SIGNED R� TITLE <br /> k <br /> DRAW PLOT PLAN ON REVERSE SIDE '` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> ' APPLICATION ACCEPTED BY DATE Y -7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> I INSPECTION BY , >WV DATE 2 ; ;LZ INSPECTION BY DATE 1 <br /> E H 1426 Rev. I-74 <br />