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SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FPS OFFICE USE: 1601 E. Hazelton Ave., .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate- Issued 7- <br /> (Complete In Triplicate) <br /> Application is Aereby 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` CENSUSTRACT ' <br /> TRACT <br /> Owner's Name Phone <br /> �.� <br /> Address City <br /> Contractor's Name `-[ .License W00e)0 Phone z3-` / <br /> a Z—.: v a <br /> TYPE OF WORK � <br /> Check : NEW WELL /7 DEEPEN j I RECONDITION /_7 DESTRUCTION /_7 <br /> c <br /> j PUMP 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 WELL PUBLIC DOMESTIC WELL C� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> l Industrial Cable Tool Dia. of Well Excavation <br /> E Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �r <br /> i Irrigation Gravel Pack Depth of Grout Seal \ <br /> i Cathodic Protection Rotary Type of Grout <br /> Disposal sOther Other information <br /> Geophysical , Surface Seal Installed By: <br /> .PUMP INSTALLATION: Contractor d <br /> F Type of Pump ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done -cod* <br /> PUMP�.REPAIR: �` / State' Work Done r <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth ,, <br /> Describe Material and Procedure <br /> j 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 onanew 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 best of my kn_owledgeand_bellef. .I.,WILL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND N...�. I`N§PEgE1ON. <br /> SIGNED XI TITLE ���, __-•- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �'27 . <br /> 1 .APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II INSPECTION PHASE IN INSPE ION <br /> INSPECTION BY ATE INSPECTION BY AAT <br /> 1177 -2K <br /> j E H 1426 Rev. 1-74 _. . <br />