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ry SAN JOAQUIN LOCAL HEALTH DI - <br /> rFOR.:06FIFICE USE: STRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77S6t�J <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 _ � . <br /> . d +�GSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 16771? <br /> City ' <br /> Contractor's Name ` ` <br /> License. # d ./ Phone 522- <br /> TYPE <br /> 2JTYPE OF WORK (Check): NEW WELL jg' DEEPEN '/_7 RECONDITION DESTRUCTION /7PUMP INSTALLATION/ / PUMP REPAIR '/ PUMP REPLACEMENT 17 <br /> Other E7 —. <br /> DISTANCE TO NEAREST: SEPTIC TANK4W4 'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERItr?�� <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 <br /> �^ Domestic/private Drilled _. Dia-.-;_-of Weli-Casi g-- - •• <br /> -Dome stic/pub lic'"_- Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal .1 i. <br /> Cathodic Protection Rotary Type of Grout ' • <br /> Disposal Other Other Information <br /> —Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> l,,, <br /> Type of Pump A.P. 7777 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP :REPAIR: State Work Done ` <br /> PES;TRUCTT '' <br /> ON OF WELL. Well Diameter Approximate Depth <br /> D scribe Material an Procedure <br /> Of <br /> l hereby agree d comply with-,all law and regulation o the S n J aquin Loca a th Dist ict <br /> anCalif <br /> d .the State of o�rn�ia4ertaining 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 /> WELk- DRILLERS REPORT of the well and notify them before putting-the..well. in.use.... The above <br /> information is true to the-best.o€ my knciwledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRLGR TO G OUTING AN FINAL N PECTION <br /> SIG [ED TITLE , <br /> RAW LOT PLAN ON VERSE SIDE <br /> FO <br /> PHASE I ART T USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADD IONAL COMMENTS: "I 172 <br /> P II/G,3ROJJT INSPECTIQX PHAAE IU FINAL INSPECTI N <br /> ECTION BY DATE fINSPECTION BY DATE <br /> -H 1426 Rev. 1-74 uIel _.Iry `cfre., h/7q 9M <br />