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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> __FOR­OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,77— Dj <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED Date Issued . /S-)') <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 and the Rules a Regulations of the Sa aquin Local Health District. R <br /> JOB ADDRESS/LOCATION �� � / �� CENSUS TRACT <br /> Owner's Name Phone <br /> Address �`� City <br /> Contractor's Name '� License' Phone ' <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / 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 p . <br /> Industrial Cable Tool Dia. of Well Excavation V, <br /> 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 C <br /> -- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed, By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done a-� <br /> PUMP .REPAIR: / / State Work Done <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 themSan. Joaquin Local Health District . <br /> and the State of California pertaining to or regulating well 'coristruction. Within FIFTEEN DAYS <br /> rafter completion of my work on a new well, I will furnish the S•an,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 knowledge. and}belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN AL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY % DATE 7_ , <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 9 •/a. - 7'? <br /> ; 1/77 _ 2M <br />