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K SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. #13 <br /> I Telephone : (209) 466=6781 rtX �-21 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W. q <br /> THIS PERMIT EXPIRES 1 YEAR.FROM:DATE ISSUED Date IssueREC. 2 2 1977J. <br /> , <br /> t (Complete In Triplicate) . <br /> Application is hereby made toIthe 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 /> I <br /> JOB ADDRESS/LOCATION '.27e, CENSUS TRACT ' <br /> Owner's Name P Phone <br /> Address '� � ` <br /> .�_ city <br /> Contractor's Name //J �J License #-Vd'& Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION Y/ PUMP REPAI / PUMP REPLACEMENT /_7 <br /> 0`ther <br /> DISTANCE HO'NEAREST - <br /> TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial '! Cab1e Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t i Rotary Type of Grout <br /> Disposal .1 Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contracto�l� <br /> Type of Pump 4 H.P. y' <br /> r � <br /> PUMP REPLACEMENT: / P State Wdrk Done <br /> PUMP_:REPAIR-: / /. ---S•tabe--Worrk- Done <br /> DESTI2UCTIOIV OI inTELLi We11 Diameter T Approximate Depth <br /> Describe Material and Procedu " <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 e best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN INAL INSPECTION. <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY -20-77 dr as Gam, <br /> PHASE I ! f raeor dv Se!dl�� <br /> APPLICATION ACCEPTED BY 'IN DATE <br /> ADDITIONAL COMMENTS: 1 ZA <br /> CJ <br /> PHASE II GROUT INSP CTION PHASENII/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 �.. b�7.7 _ 2M <br />