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,T <br /> 0 SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOF OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77' P b <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -c? lB-7? <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 ismade in compliance with San.".,'Joaquir <br /> County Ordinance No: 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> ' Owner's Name i/� _ 6o Phone <br /> t Address. 2 rr <br /> City � t <br /> Contractor's Name License # /y3-2j n`hone " <br /> r <br /> F 4 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other- / <br /> / --- <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " PIT PRIVY T. <br /> L SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ <br /> 4 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> y Domestic/private Drilled Dia, of Well Casing , <br /> Domestic/public Driven Gauge of Casing <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 /> PUMP INSTALLATION: 'Contractor_. <br /> ,.Type of "Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> z:. PUMP FAIR; '/Tc/ State Work Done <br /> h `s <br /> DESTRUCTION OF WELL: Well Diameter " V Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all Jaws and regulations of the San Joaquin Local. Health Distract <br /> And the .State of California pertaining. to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of mywork 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 k owled e d belief. I 'WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A. FINAL EC <br /> SIGNED ITLE <br /> t <br /> W "P AN ON rlbfRSE SIDE' <br /> FOR DEPARTMENT USE ONLY <br /> { PHASE I <br /> 0 <br /> R APPLICATION ACCEPTED BY, DATE <br /> ADDITIONAL COMMENTS: <br /> -,. PHASE_ II UT' NS ECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY ' " DATE INSPECTION BY DATE ;2,- ti <br /> V. <br /> I H 1426 Rev. . 1, -.74' 214 <br /> f <br />