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F ` <br /> ¢ Y T <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 �� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued` <br /> a (Complete In Triplicate) 07-- Y?0 - o <br /> Application is hereby made to the San Joaquin Local Health District for a permit to Istruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 18P and t Rules and Regulations the San Joaquin Local Health District. <br /> �. <br /> JOB ADDRESS/LOCATI N .rte' �US TRACT <br /> Owner's Name Phone <br /> Address' City 1 <br /> Contractor's Name License <br /> Ott P;'3 25Phone <br /> ( TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITI /�/ DESTRUCTION /? J = <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k 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 Well Casing <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ., Type of Grout # <br /> Disposal I Other Other Informa'tiori t <br /> Geophysical Surface- Seal Installed By: <br /> 4 <br /> PUMP INSTALLATION: Contractor _ H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PU14iP�:REPAIR: - r/ .State-Work Do - <br /> IDESJIUCTION OF WELL: Well Diameter F Approximate Depth <br /> Describe Material and Procedure <br /> 11 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 thewell 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 D A FINAL INSPECTION. <br /> SIGNED ��� � TITLE 1 <br /> (DRA PLOT PIAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> [APPLICATION ACCEPTED BY �` DATE ��� � <br /> kADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rain_ 1_7L, <br /> 1777 2M <br />