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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 41 Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77� <br /> THIN PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued F-30, 7 7 <br /> (Complete In Triplicate) i. <br /> Application is hereby made to Ue 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 andiIthe Rules an ulatians of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � , - CENSUS TRACT _ <br /> Owner's Name I Phone <br /> 1 -- <br /> Address ��I City <br /> Contractor's Name "telJ4AeLicense # M60�_ Phone <br /> i --- f <br /> f <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION REPAIR /-7—'PUMP REPLACEMENT / <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 SPECIFICATIONS <br /> Industrial _ 1 Cable Tool Dia, of. Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing/,X <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth.of Grout Seal: <br /> Cathodic 'Protection t Rotary Type of Grout <br /> Disposal [ Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION:- Contractor <br /> 'Type of Pump H.P. <br /> PUMP REPLACEMENT: / / StateWork Done a-a PICA <br /> 06" <br /> PUMP .REPAIR: / / State_ Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ---Des _b <br /> I hereby agree to comply withiallTlaws Tand Tregulations of the San Joaquin Local Health District F <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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING .4n A FINAL}IINS ECTION. <br /> SIGNED TITLE <br /> ft (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � ' 7 <br /> APPLICATION ACCEPTED BY Gt✓ DATE J3�— 7/ <br /> ADDITIONAL COMMENTS: it <br /> PHASE II GROUT INSPECTIONPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE A <br /> INSPECTION BY f DATE :nO' 7 <br /> E H 1426 Rev- 1-74 /_7 2M <br />