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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S- 77 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ON A A A4. a /U CENSUS TRACT <br /> d <br /> Owner's Name _ .� t� .,.,.. - ......_ .., Phone 3,.?4e A0/ r--- <br /> Address — . City B®/ F <br /> Contractor's.Name Al <br /> Licen`se1 Phon <br /> N <br /> TYPE OF WORK (Check): NEW WELL ,/_7 DEEPEN /7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> -- r <br /> j --- <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> « Industrial ° Cable Tool Dia. of Well Excavation v <br /> 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 I Other Information <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /''/ State Work Done <br /> PIWI .TREPAIR: /7 State Work Done _ <br /> ES:TRUCTION OF WELL: Well Diameter -µ Approximate Depth If"® <br /> . t <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 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 Hefore,putting the-well in.use.. The above <br /> information is true to the-best of my knowledge .ar0 belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GR UTING AND A F INSPECTION. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN-ON REVERSE SID <br /> XOR DEPARTMENT .USE ONLY;, ,_ k <br /> PHASE I if <br /> APPLICATION ACCEPTED BY DATE , l/ / 7J` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL—INSPECTION/ <br /> INSPECTION BY DATE f l 731 BY DATE <br /> E H 1+26 Rev. 1-74 <br /> 4 1_79_2M ;/ <br />