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.� SAN JOAQ&N L``§CAL-HEALTH DISTRICT <br /> FOF .QrFICE' USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 77-2.3-)--v <br /> -�yv <br /> N <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued _ -7 <br /> N (Complete In Triplicate) <br /> y Application 'is hereby made to the San Joaquin Local health District for a permit to construct <br /> E and/or install the work herein described. This application is made in compliance with San•Joaquil <br /> I . County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> k JOIE ADDRESS/LOCATION { r CENSUS TRACT <br /> l _ <br /> Owner's Name Phone ' <br /> r <br /> Address City . <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/7 RECONDITION /7 DESTRUCTION %' -� <br /> "'PUMP IN5 TION / / 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 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:—. PUBLIC .DOMESTIC WELL ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI A IONS <br /> Industrial Cable Tool "Dia. of Well Excavation q� <br /> Domestic/private Drilled .> Dia. of Well Casing <br /> Domestic/public Driven :Gauge of Casing C <br /> Irrigation Gravel Pack Depth_ of .Grout Seal. O ' <br /> Cathodic Protection Rotary Type .of Grout <br /> Disposal Other �.. Other Information , <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION.- . ;'Contractor <br /> -Type ofaPumpH;P. . <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 r <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 /> : informatiop%is true to the best of my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION,— <br /> PRIOP,; TO UTING 'AND INAL INSPECTION. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN 0 VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE' I <br /> APPLICATION ACCEPTED B`Y DATE <br /> ADDITIONAL COMMENTS- <br /> UT II GROUT IN ,P Ir INAL INSPECTION <br /> IINSPECTION B DATE INSPECTION. BY 4 DATE 7`7 <br /> J, E H 142 Rev. 1-74 � !:/75 2N1 � <br />