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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. pjA <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct' <br /> I <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 CENSUS TRACT <br /> Owner's Name Phone <br /> ,a C.&L a 9 <br /> Address .AaQ97,0, City <br /> Contractor'sNamec_.c� <br /> �3Lleense # j/�JPhone ��a2 . <br /> TYPE OF WORK �(Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_/ DESTRUCTION /7 <br /> y PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEARES.T.sSEPTICTANK S ' SEWER LINES PIT PRIVY <br /> SEWAG.EDISPOSAL FIELD Y0 f CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> `"" ; <br /> �..� � _.. ,Cable Tool Dia, of Well Excavation � <br /> —Domestic/private <br /> Industrial Drilled Dia, of Well Casing (o ' <br /> Domestic/public Driven m Gauge of Casing <br /> Irrigation Gravel Pack,, Depth of Grout Seal g� <br /> Cathodic Protectionz_-Rotary !, , �f <br /> Type` of Grout <br /> Disposal Other Other Information - �- <br /> Geophysical <br /> Surface,Seal Installed By: <br /> PUMP INSTALLATION: Contractor i t <br /> Type of Pump H.P. <br /> _ l <br /> PUMP REPLACEMENT: � <br /> State Work Done � <br /> PUMP .REPAIR: <br /> /7/ .-State workDone <br />)ES'TRUCTION OF WELL: Well Diameter <br />--� — A Approximate Depth <br /> Describe Material and Procedure <br /> T hereby agree to comply with all laws 'arid 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 /> Lnformation is true to. the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ! <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE_ <br />'RASE I FOR DEPARTMENT USE ONLY 13 <br /> APPLICATION ACCEPTED BYDATE 0 hp, ! <br /> ADDITIONAL COMMENTS: € <br /> PHASE II GROUT INSPACTION PHASEI FINAL INSPECTIO <br />[NSPECTION BY VZrLAn DATE / 7 INSPECTION BYDATE / <br /> E H 1426 Rev. 1-74 1177. " 2M. 74` <br />