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f <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-�1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3—io `77 <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 /> , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �O <br /> `'�CBNSUS TRACT <br /> Owner's Name Phone <br /> Address @ City a <br /> Contractor's Name License # Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ I DEEPEN '/ I RECONDITION I I DESTRUCTION j <br /> PUMP INSTALLATION I I PUMP REPAIRj / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITaPRIVY <br /> SRWAGE_DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE.DOMESTIC WELL PUBLIC.DOMESTIC WELL <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> Industrial Cable Tool Dia. of Well Excavation \n <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic f public ""a" '" Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information v+ <br /> Geophysical Surface Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.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 60. C4 <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 <br /> li 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 TOGROUTING D A F AL INSPECTION. <br /> SIGNED r == TITLE._ <br /> D TPL T PLAN 'ON RE FRSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE T I/F AL INSPECTION <br /> INSPECTION BY DATE '"'Z INSPECTION BY ['• DATE <br /> - . 3/76 2M <br /> R H 142Fi Ttav_ 1--74 <br />