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E f <br /> � y <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR.'OFFICE-USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit`No. 7 7-t/6µfo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a .27 <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 gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ON CENSUS TRACT <br /> Owner's Name I Phone <br /> City _ <br /> Address. - ' <br /> lax <br /> Contractor's Names _ License �Phone_ <br /> _ _ d <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / '/ PUMP REPAIR / / PUMP REPLACEMENTS'�-7 " ` `— <br /> Other`/ / <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 /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS cll�' <br /> industrial Cable Tool Dia, of Well Excavation \ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigatt-on Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection Ro,tary Type of Grout <br /> f Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> -. / .� <br /> PUMP REPLACEMENT: _- State Work`Done A Y 6{��✓ �� - <br /> PUMP REPAIR: / / State Work Done „.-DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I d <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 DAIS <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 C L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL INSPE TION.N\ <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)l <br /> FOR°DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i' DATE 7-7- 3 -77 <br /> ADDITIONAL COMMENTS: A <br /> PHASE II GROUT INSPECTION P /FI INSPECTION <br /> INSPECTION BY DATE "fINSPECTION BY DATE <br /> y-z/"77 <br /> 1- E H� 1426 Rev. 1-7G <br /> IIZ7 2M <br />