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SAN JOAQUIN LOCALHEALTHDISTRICT <br /> FOFF�sOFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (204)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77--//7 j <br /> THIS'. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued E20, 7 <br /> (Complete In Triplicate) <br /> Application is Hereby made to Ahe San Joaquin Local Health District for a permit to construct' <br /> and/or install the work hereinl. described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and Ahe Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name Phone — El e)Q <br /> Address °' City <br /> Contractor's Name J License Itg� Phone ,� ! <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_/ RECONDITION / .-DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /T_/ <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITiPRIVY <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 a <br /> Industrial. F Cable 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 f- Rotary Type of Grout <br /> i <br /> Disposal Other Other I=nformation <br />::a, Geophysical Surface-Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP �.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - r - - -. - 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 1 <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work onja 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 />?RIOR TOG UTING AND A FINAL IN5 ECTION <br /> SIGNED TITLE 7a <br /> + (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> h <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHA§E IN NSPECTION { <br /> INSPECTION BY DATE INSPECTION BY DATE 4g�- Z4- 77 <br /> E H 1426 ' Rev. 1-74 <br /> 1/7.7 2H <br />