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y SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 77� <br /> THId PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued?'-.)-q. <br /> 27 <br /> C,: ! (Complete In Triplicate) <br /> Application is hereby made totthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereirildescribed. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and ,the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i`� t <br /> c ENSUS TRACT <br /> Phon j_ <br /> Owner's Name <br /> City <br /> Address -,,2- 2=3 6 = <br /> License Phon <br /> e.3 <br /> Contractor's Name <br /> L <br /> TYPE OF WORK (Check) : -NEW WELL/ / DEEPEN/ / RECONDITION /. / DESTRUCTION /_7 <br /> PUMP INSTALLATION I J PUMP REPAIR / C PUMP REPLACEMENT /7 <br /> Other <br /> t <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 Cable Tool Dia.. of Well Excavation <br /> Domestic/private,,; , Drilled Dia. of Well Casing y <br /> -Dome-stic/public Driven , F Gauge of Casing - 9 <br /> Irrigation I Grave'l`Pack bepth of Grout Seal <br /> Cathodic Protection ;1 Rotary Type of Grout <br /> Disposal : 1 Other Other Information <br /> Geophysical r � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ­7� <br /> PUMP REPLACEMENT: / tate Work Done <br /> PUMP REPAIR: ]State Work Done <br /> Nl <br /> DESTRUCTION OF WELL: WelliDiameter ` 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 /> k after completion of my work' on a new well, I will furnish the San Joaquin Local Health District 1 <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 k owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR0 NG D A F INSPECT <br /> SIGNED TITLE <br /> W Pt T' PLAN REVERSE SIDE <br /> FOR DEPARTMENT _USE ONLY <br /> PHASE I ' � � <br /> � DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ! PHASE I;II/IINALINSPECTION <br /> PHASE II GROUTINSPECTION INSPECTION BY 'DATE' INSPECTION BYTE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />