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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&*;*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 B&J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7/ -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 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 0 e eD p l <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Phone <br /> Address �a� _ Fo or _// city Tc � <br /> Contractor's Name ���,/� License <br /> #0�� Phone cf5��g�lJ <br /> TYPE OF WORK (Check): NEW WELL 'jg DEEPEN -7 RECONDITION /_7 DESTRUCTION f7 ' <br /> i PUMP INSTALLATION /7� PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER! i <br /> PROPERTY LINE,50PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ) TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing l 2 <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 's — <br /> - <br /> Dis veal <br /> p Other Other Information <br /> Geophysical t ! Surface Seal Installed By: acs c i <br /> I <br /> PUMP INSTALLATION: , Contractor , <br /> Type of Pump _ H.P. <br /> i <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP I REPAIR:_. : <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _' Approximate Depth, <br /> Describe Material and Procedure t <br /> I hereby agree to comply with all laws and regulat-ions---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 th and notify them before putting the..weli in-use... Theiabove <br /> information is to a bee of kno edge; and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI INAL INSPE IO . <br /> SIGNED - -!TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE " <br /> FOR DEPARTMENT USE ONLY 0 <br /> PHASE I '( <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:' j <br /> PHASE II-GROUT INSPECTION PHASE' III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f22 <br /> jj <br /> E H 1426 * Rov_ i-7A -7N nu <br />