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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 7->3`iP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z?—//-4 7 <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 _ C = .w CENSUS TRACT <br /> Owner's Name Phone3 <br /> Address (� �� � city 1� <br /> Contractor s Name . <br /> License # :V60 Phone d�3 9 <br /> a <br /> TYPE OF WORK (Check): NEW WELL. L7 DEEPEN %T RECONDITION DESTRUCTION LJ <br /> PULP INSTALLATION / / PUNP REPAIR'/ / PUMP REPLACEMENT <br /> Other / / <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 NEU <br /> INTENDED USE TYPE OF WELLSPECIFICATIONS <br /> PECIFIC TIONS <br /> CONSTRUCTION r��.ipswaa,..,�.� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ \ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical sical Surface Seal Installed BY: <br /> P <br /> PUMP INSTALLATION% Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �a <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION DB WELL: Well Diameter Approximate Depth ; _ <br /> Describe Material and Procedure <br /> I 'hereby agree to comply with all laws and regulations of the San Joaquin Local Health Bfstiict <br /> and the State cif California pertaining to or regulating well construction. Within FIFTRIN DAT <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,,FPR A GROUT I4SPECTION <br /> PRIOR TO GROUTING AN FIN INSPE ON. Gt�Z' <br /> SIGNED TITLE <br /> W. PLAN 'ON . E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 3' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL WMMINTS: <br /> PHASE FIN INSPECT109 r <br /> PRASE II iIESPECTION <br /> INSPECTION BY �� DATE INSPECTION BY <br /> DATE <br /> V76 <br /> E 9 1426 Rev. 1.74 <br />