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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. )) 3 7jd <br /> 77-S-8w p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 describe is ion is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the RuledRegulations of t an Joaquin Local Health District. <br /> JOB ADDRESS/�+pN <br /> _�T <br /> << CENSUS TRACT <br /> Owner's Name �� Phone i <br /> Address City <br /> f <br /> Contractor's Name /' C.SW14A-e--<Ak License # AMnone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK/` SEWER LINES PIT PRIVY <br /> SEWAGE ➢ISPOS �ELD ter' CESSPOOL/SEEPAGE PIT qL-OTHER <br /> PROPERTY LINH - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS " <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 )eRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY:.,•_„� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �_ H.P. <br /> PUMP REPLACEMENT: . / / State Work Done ` <br /> PUMP .REPAIR: / / State Work'Done <br /> DESTRUCTION OF 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 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 F R A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT <br /> SIGNED, - <br /> TLE <br /> RAW PLT LAN 'ON RE ERSE SIDE <br /> FOR PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `7 <br /> ADDITIONAL COMMENTS: <br /> PHAU JI GROUT INSPECTIO PHAS III/FINAL INSPEC IOPT <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> , E H 1426 Rev. 1-74 <br /> 3/76 2M <br />