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� V e <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-ze,,z � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <br /> I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install theworkherein 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 CENSUS TRACT <br /> Owner's Name 6=12Z1 <br /> Phone <br /> Address <br /> + City �� <br /> Contractor's Name � _ License # phone <br /> TYPE OF WORK (Check);, NEW WELL / / DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> rPUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ' <br /> Other <br /> ' f <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD._ 4 CESSPOOL/SEEPAGE'PIT OTHER <br /> *_• PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE is ``TYPE OF WELL i CONSTRUCTION SPECIFICATIONS \ <br /> Industrial- Cable Tool Dia, of Well Excavation <br /> y Domestic/private Drilled * Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection : Rotary �.uType_of__Grout ___. <br /> Disposal Other Other Information <br /> Geophysical `"F Surf ace Seal"Installed"B "" <br /> "PUMP INSTALLATION: Contractor <br /> : , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP .REPAIR: / / State Work Done ;E. <br /> DESJRUC_TION 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. my knowledge and belief. . I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NIN AND A FINAL �INSPE TON. } <br /> SIGNED <br /> +-v r-_.(DRAW-_-LOT;.PLAN-..ON -REVERSE SIDE)_. <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY LN DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION�/ i P II/FI INSPECTION <br /> INSPECTION BY DATE 1" INSPECTION BY DATE <br /> 1 <br /> E H 1426 Rev. 1-74 1 X77 2rii <br />