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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICEUSE; 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> I , Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�Q'�✓ <br /> (Complete In Triplicate) <br /> Application his hereby made ;to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the work herein described. This application is made -in compliance with San Joaquii <br /> County OrdinanceNo. 1862 and th Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIQ CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address s V\ . <br /> City <br /> Contractor's Name License #-:140(&Phone <br /> x <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION <br /> Other / / PUMP REPAIR / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST SEPTIC TANK. SEWER LINES PIT PRIVY ' <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> : PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> M INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial f Cable Tool Dia, of Well Excavation <br /> } Domestic/private t Drilled Dia—of We11 Casing <br /> Domestic ' �y..'� ""` - -.v- — _. <br /> /pudic R Driven - Gauge of Casing <br /> Irrigation _- .�.�� = . .. <br /> - Gravel Pack-- 3epth-ofGrout'5ea1— <br /> Cathodic Protection i Rotary k eY Typof Grout <br /> Disposal i Other Other Information <br /> Geophysical ' Surface Seal Installed By: <br /> -PUMP INSTALLATION:, I <br /> Contractor <br /> A Type {o£ Pump H,P. . . > <br /> PUMP REPLACEMENT: State Work Done <br /> � PUMP 'REPAIR: / / State Work Done <br /> i I <br /> IDES•TRUCTION OF WELT : Well Diameter Approximate Depth <br /> f; Describe Material and Procedure <br /> iI 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 'eonstruction. 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..wel.l 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 G UTING FINAL INSPECTION. <br />' SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> " FOR DEPARTMENT USE ONLY <br /> PHASE I <br />{ APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS; <br /> 5 <br /> PHASE II. GROUT INSP ION PHA II/F AL INSPECTION <br /> INSPECTION_HX � F� ,DATZ- INSP�;CT.ION_BX DATE. <br /> I <br /> Z;7 V <br /> E H 1426 Rev. 1-74 <br />