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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77- /0D <br /> l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -! �7 <br /> (Complete In Triplicate) <br /> Applicati In is Ysereby made to��the San Joaquin Local Health District for a permit to construct <br /> and/&d1iijance <br /> tali the work herein described. This application is made in compliance with San Joaquin] <br /> Couno. 862 and the Rules an Re atiopas of the Sa J aquin Local Health District. <br /> Q <br /> JOB ADDRES, /LOCA ri�.cvill CENSUS TRACT <br /> Owner's Name Phone4Sv -�J �✓ <br /> Address es-e city' n <br /> Contractor's Name "��°`� License <br /> TYPE OF WORK (Check) : NEW WELL / f DEEPEN ,/ / RECONDITION /`/ DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / / 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 ELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 1' °'• CONSTRUCTION SPECIFICATIONS \, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Cathodic Protection f Rotary Type of Grout <br /> Disposal i Other 'Othe Information <br /> Geophysical Surface Seal Installed By: <br />-PUMP INSTALLATION: Contractor <br /> Type of Pump` V H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR:---o7 State_Work aDone <br /> DES-TRUCTION OF WELL: Well Diameter , Approximate Depth <br /> Describe Material ,and Procedure <br /> r F` <br /> I hereby agree to comply with all lawsI'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 onIa new urell„3 will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and•not16 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 GROUTING AND INAL INSPECTION.' <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON-REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE+� = �,� DATE ��� " �, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,,� DATE <br /> � : 11 Z7 2M <br /> Rev. P <br /> E H 1426 . 1-74 �- <br />