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m put SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi:OFFICE USE: 1601 E. Hazelton Ave. , Stockton,, Calif. <br /> ( Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT. EXPIRES l YEAR FROM DATE ISSUED Date Issued /�2-7_76 i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construc ' . <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 th San Joa ui Local Health District. <br /> (91 <br /> JOB ADDRESS/LOCATI -J 77 CENSUS TRACT �r <br /> Owner's Name ► Phone�� <br /> Addressd Ci <br /> 1 <br /> Contractor's Name License �(g: 37.? Phone <br /> TYPE OF WORK (Check): NEW WELL L-7w DEEPEN /��`RECONDITION %T DESTRUCTION J7 -- <br /> Y <br /> PUMP INSTALLATION/ / PUMP REPAIR /_7 PUMP REPLACEMENT f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E PROPERTMINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation 0 <br /> Domestic/private T Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack i Depth of Grout .Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal t Other Other Information Vi <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: : Contractor <br /> Type .of'Pump H.P. <br /> ,�. <br /> PUMP REPLACEMENT: State Wor ��PiriJ� j 14 � <br /> PUMA_REPAIR: `7-- �r -_ <br /> .. / S't�te.t Werk DoneY- <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 the San YJoaquin 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 we11 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 />'RIOR TO GROU ING `AND A FINAL INSPECTIO <br /> SIGNED � _ <br /> TITLE 1:10 ....a,,, <br /> DRAW PLOT PLAN ON REVERSE SIDE. <br /> PHASE I / OR DEP TMENT USE ONLY <br /> kPPLICATION ACCEP D BYAvo a <br /> WlSoni DATE /� •3 <br /> kbDIT.IONAL COMMENTS t — � <br /> PHASE II GROUT INSPECTION P INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY4 MDATE -- 7 <br /> i'H 1426 -`Rev. '1-74 C ou , 3 <br />