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od <br /> SAN JOAQi3IN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;77 <br /> tI <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued za-1 7g ` <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> a -7do <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ {��r�eS ' Phone <br /> Address .57,.30 - '� City <br /> Contractor's Name l der License # Phone 6?.2-,7 <br /> i a <br /> TYPE OF WORK (Check): NEW Wil L/tel! DEEPEN -/? RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR j_/ PUMP REPLACEMENT /_7 off r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK JjCLb SEWER LINES Igo 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 q <br /> Industrial _ .Cable Tool Dia. of Well Excavation (N� <br /> 1 <br /> _/Domestic/private �CDrilled Dia. of Well Casing <br /> -Domestic/public Driven Gauge of Casing V <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal r i Other Other Information <br /> Geophysical Surface Seal Installed B 4s <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump f, H.P. or <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP"'.REPAIR: / / State Work Done <br /> E&TRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in.use.. The above <br /> information is true to the of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL,IINSPECTION. <br /> SIGNED TITLE <br /> t . (DRAW PLOT PLAN ON REVERSE SIDET <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -- <br /> ADDITIONAL COMMENTS: E <br /> P E ROUT IN9PECTION PHASE 4IT7ZINAL INSPECTION t <br /> INSPECTION BY L DATE - r ; INSPECTION BYDATE -- -�, <br /> + E H 1426 Rev. 1-74 1-74 2M <br />