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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. C <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77- 1-391 <br /> THIS; PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /� <br /> (Complete In Triplicate) t <br /> Application is hereby made to,ithe 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 . e o CENSUS TRACT - <br /> Owner's <br /> -- C /�A �� � 4s!`7 '�nC� _ - -------- - -- - � <br /> Owner's Name PALA 0 Phone e� (6 <br /> Address <br /> Contractor's Name ke ! u a. License #,2 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /—/ DESTRUCTION /7 _ R <br /> PUMP INSTALLATION / ­PUMP PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other J, / <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 I Cable Tool Dia. of Well Excavation h' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br />___A,,-irrigation E Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 11 Rotary Type of Grout A <br /> Disposal I. 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 ve49~)�" - <br /> PUMP-�REPAIR: State Work Done - <br /> DESTRUCTION OF WELL:4, Well. Diameter Approximate Depth <br /> Describe Material and Proceduref <br />-I hereby: agree. to'.. comply. withtall laws and regulations of the-San Joaquin Local Health District <br /> and`the•State of California pertaining to or regulatin - <br /> g.wellconstruction. Within FIFTEEN DAYS <br /> after completion of my`taork on a new well, I.will,Rd ish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well.. and notify-thein before puttingthewell 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 TOG OUTING AND A FINALI INSPECTION. <br /> SIGNED mow` _ TITLE. <br /> rF ,. -:. (DRAW PLOT PLAN ON REVERSE SID ) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BY DATE In-2 -fl7 <br /> ADDITIONAL COMMENTS: LIZI <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,3-,A�t9 <br /> W77 2M <br /> E H 1426 Rev. - 1-74 <br />