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SAN JOAQUIN LOCM, HEALTH DISTRICT <br /> F01*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77J g�S <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 egulations of the San Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION - , CENSUS TRACT. <br /> Owner's Name exi <br /> oy-C-S <br /> ' Phone I <br /> Address - <br /> G"`'�r` City <br /> Contractor's Name as License #� e4 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_% RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / pump REPLACEMENT f <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 �J11 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 4 <br /> Domestic/privateDrilled Dia. of Well Casing '� <br /> Domestic/public Driven Gauge of Casing, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary. Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor a , <br /> a <br /> Type of Pump' y <br /> H.P. <br /> .5 a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done t <br /> DESTRUCTION OFrWELL: Y� Well Diameter - Approximate Depth <br /> ti y <br /> Describ-e 'Materta-1-arid`-Pr6cedure-"-_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. thp. 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 />'RIOR TO G TING A INAL INSPE ION. <br /> SIGNED TITLE _ + <br /> (DRAW PLOT PLAN ON REVERSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I g <br /> kPPLICATION ACCEPTED BY DATE <br /> k.DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -- -t DATE -7 <br /> E H 1426 Rev- 1-74 .. . 0/77 2M <br />