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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> io- OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> ljo4 <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 � �'� a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,L­7`7J. <br /> t (Complete In Triplicate) <br /> Application is hereby made tol1the 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 Son Joaquin <br /> County Ordinance No. 1862 and 1the Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION �G� CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address c9e r;1 i / s City <br /> Contractor's Name /"// License # Phone <br /> 7 i. <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT ' <br /> Other /1 <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 Q� <br /> Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public J Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I ' Rotary Type of Grout <br /> f .Disposal. i Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 1 , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: / / State Work Done 9 . <br /> - State Work Done �� , ^ w �✓ 'V/ <br /> PUMP ^.REPAIR: I I ;� - <br /> Approximate Depth <br /> `. DESTRUCTION OF WELL: Well Diameter pp <br /> Describe Material and Procedure <br /> I hereby agree to comply'vith all laws and regulations of the- San Joaquin •Local Health-District <br /> and the State of California pertaining to or regulating; well-'coustruction. 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 <br /> boveinformation is true to the best of my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> EPRIOR TO GROUTING AND NAL INSP CT ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> � FOR'DEPAR MENT USE ONLY <br /> PHASE I DATE __5! <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I <br /> PHASE I OUT'INSPECTION P /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 :~ - <br />