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r. " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Fazel.ton Ave. , Stockton, Calif. <br /> Telephone: (209)~466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ <br /> 77- 1101/o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J <br /> (Complete In Triplicate) <br /> Application is hereby 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 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 Q e Im rdoh I CENSUS TRACT <br /> Owner's Namee Y <br /> Phone/04; <br /> i <br /> Address r VVrZzzie_ u City G '4'a <br /> i <br /> Contractor's Name JfliLicense Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other /_7 <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 &.-- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.of�Wel 'Casing <br /> Domestic/public Driven Gauge of Casing 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed-By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / State Work Done µ 1 <br /> PUNP .REPAIR: / / <br /> State Work Done, j <br /> DESTRUCTION OF-WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <br /> s„ <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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING - A FINAL NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAli� <br /> 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION P E / NAL INTION <br /> IliSUCTION BY DATE INSPECTION .BY. DATE <br /> 1. 177. 214 <br />