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' s•�. 4•_-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1?' <br /> F0pFFIC S: '` 11V 1.601 E. Hazelton Ave. , ,Stockton, Calif.' <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-77-LINO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -Zn-77 <br /> (Complete In Triplicate) 22-0— 060„zj <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and%or install the work herein described. This application is made in complianeg with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _9JOB ADDRESSAOCATION fYFhp-4-we-enCENSUS TRACT. <br /> , girl -d--()live <br /> Owner s Name Phone } <br /> Address � <br /> City <br /> Contractor's Name <br /> License . Phone � Q <br /> d � QA <br /> _ <br /> i <br /> TYPE OF WORK (Check): NEW WELL J DEEPEN 7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION Imo'. PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other I I T v N ! <br /> DISTANCE TO'NEARE T: SEPTIC TANK SEWER LINES PIT PRIVY �I+ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT QTR N <br /> PROPERTY LINE r PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Indi�strial Cable Tool Dia, <br />`= of Well Excavation i <br /> Domestic/Private Drilled Dia. of Well Casing e, <br /> Domestic/public Driven Gauge of Casing 6z, <br /> Irrigation Gravel Pack Depth of Grout Seal- -� <br /> Cathodic Protection Rotary Type of !Grout --- P Mt <br /> Disposal Other Other Information <br /> y Geophysical Surface Seal Installed B _': -� <br /> P,IJMP INSTALLATION: Contractor <br /> Type of Pump H.P. . . . <br /> PUMP-, REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR; / / State Work Done a <br /> WS•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure z" <br /> Iyhereby 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 FIYTEEN 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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION . <br /> PRIOR TO GROUTING. ANp A FINAL INSPECTION, <br /> SIGNEDTITLE1. 5� <br /> E 7 <br /> (DRAW PLOT PLAN ON REVERSE SID -- - '� <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCRPTED BY ZZZI <br /> RATE <br /> AADITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PITA II F NALI SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3 ,� <br /> ' E H 2426` Rev. I' ' 311ob7 C e1 �'r�c „ - __ sj C D1 .�_f b' 1 J.71 x <br />