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r <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk�`Orp iCE 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) _ <br /> Application'i'S 'Aereby made to the San Joaquin Local Health District for a permit to connstoruct <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 anoaquin Local Health District. <br /> JOB ADDRESS/LOCATIQ �~ <br /> «�• CENSUS TRACT <br /> Owner's Na <br /> Phone <br /> Address ^� <br /> City <br /> Contractor's Name. , <br /> License t��Phone ' <br /> [� i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /X/T RECONDITION /—/ DESTRUCTION /-7PUMP INSTAL TION / / PUMP" REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD / �,CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIV.AT�MESTIC WELL PUBLIC DOMESTIC WELL <br /> Industry USE . TYPE OF WELL CONSTRUCTION SPECIFTCATIO S <br /> Industrial r <br /> Cable Tool ` " e 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 Casing <br /> Grou <br /> Cathodic Protection Rotary T pe of Grout Seal j <br /> Disposal yP �b <br /> Other - Other Information 1 <br /> Geophysical Surface Seal Insta ed B : '% <br /> V . <br /> PUMP INSTALLATION: Contractor + � i ' <br /> Type of Pump -E <br /> H.P. <br /> PLW REPLACEMENT: / / State Work Done - n <br /> PUMP REPAIR: / / State Work Done <br />)ES-TRUCTION OF WELL: Well Diameterf <br /> Approximate Depth' ! <br /> Describe Material and Procedure <br /> .ereby agree to comply with all laws and regulations of the San Joaquin Local Health bistrict <br /> ind'•-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 aC <br /> 4EFL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> Lnformation is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROU ING AND A F NAL INSPECTION. <br /> i1GNED <br /> �p (DRAW PLOT PLAN ON REVERSETSIDE) <br /> !— <br /> 9�n Int F DEPARTMENT USE ONLY <br />'HASE I <br /> APPLICATION ACCEPTED B DATE �"�'" <br />,DDITIONAL COMMENTS: <br /> 047 <br /> PHASE I GROUT INSPECTION P III/ AL NSPE!g� <br />.NSPECTION BY f-J: r� n DATE INSPECTION BY DATE <br /> 'E Ap <br /> H CRlL fe `U W'�qI J <br /> 1426 Rev. 1-74 _r. m . <br />