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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rF!OF50FFICE USE:' 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 5-7*y6 <br /> j 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 a d the Rul s an.4 ltepulaj�ion of t e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION NSUS TRACT <br /> Owner's Name :21 . ,�- ,j' Phone <br /> Address d 7 City <br /> Contractors Name Co 40 i� License # 1 g3 7-i k- hone ,. -74C 7-,,4 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLISEEPAGE 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 /> )c Domestic/private Drilled 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump s ai H.P. r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP / / State Work Done r - <br /> DESTRUCTION OF WELL: Well Diameter 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 <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 4(tDfAW <br /> owledge and-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE <br /> jf <br /> SIGNED Qy a _ iTLE pv-a r. �. <br /> PLOT PLAN ON REV RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE,`'-.2-0 '7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PWE_TIlkFINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 11-77 _ 2M <br />