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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF GFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77-21-01 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued6-d 7-2, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein,• described. This application is made in compliance with San Joaquin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. a <br /> JOB ADDRESS/LOCATION � Q CENSUS TRACT <br /> Owner's Name Phone ,��` '�S <br /> • i <br /> Address /9 i City <br /> i <br /> Contractor's Name License ��o��. Phone <br /> i. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7AL <br /> PUMP INSTLATION I-PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY I LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r ' Domestic/private I Drilled Dia. of Well Casing ` <br /> Domestic/public I Driven Gauge of Casing <br /> 1 <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical <br /> � _ Surface Seal Installed B � <br /> PUMP INSTALLATION; Contractor J <br /> Type ofjPump' H.P. <br /> F <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION 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 /> 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 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 /> PRIOR TO GROUTING AND A FI AL INSPECTION. <br /> SIGNED TITLE <br /> (DRALT PLOT PLAN ON REVERSE SIDE) 1 <br /> + FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /„ _ _ DATE d-23-77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br />'INSPECTION BY DATE INSPECTION BY ATE -0`7-7-7 <br /> i <br /> 1177 2M - <br />