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SAN JOAQi1IN LOCAL HEALTH DISTRICT <br /> ^ <br /> C <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_1��4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J�I,�-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 :Wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Z p cs.e� <br /> JOB ADDRESS/LOCATION <br /> L CENSUS TRACT <br /> Owner's Name Phone <br /> Address City �... <br /> Contractor's Name (c�..... License # 7&dg4UZ- Phone G -Y,5-,9,7 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /? pump REPLACEMENT 17 <br /> Other /- <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CON5TRUCTION SPECIFICAT NS ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> — Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack `f _.._... <br /> Depth of Grout Seal C1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other I ... <br /> Geophysical ---�� nformation <br /> Surface Seal,.Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> n •� <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> . i <br /> PUMP :REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure --- <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 . j <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. T WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO .GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PI OUT INSPECTIO PHASE III FINAL INSPECTION F <br /> INSPECTION BY ' DATE INSPECTION BY 4,r DATE 21-77 <br /> E H 1425 Rev. 1-74 <br /> 1-74 2M <br />