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PIP <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr,: FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77•- �s <br /> THIS PERMIT EXPIRES l YEAR 77~�_;7 <br /> / AR FROM DATE ISSUED Date Issued �; �7� ! <br /> J (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 SD Lt✓ CENSUS TRA ;. <br /> r <br /> Owner's Name e Phone3��= 1G ? <br /> Address , ~City I <br /> Contractor's Name + .License � 7�/,f�� .�,s' <br /> r�? � 14 Phone <br /> TYPE OF WORK (Check): NEW WELL ../ DEEPEN "/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION --V PUMP REPAIR /� PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <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 Too] Dia. of ,Well Excavation <br /> Domestic/private_ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing JQ <br /> Irrigation Gravel Pack°• Depth of Grout SealI <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed 'By: PI 6;�-,o <br /> PUMP INSTALLATION: Contractor 67ss` <br /> Type ;.of Pump Ttt � �.rs-P .,.,, H.P. S� <br /> PUMPREPLACEMENT-. . . / / State Work Done <br /> PUMPf'.REPAIR " J State W -z <br /> _ ork Donet <br /> s <br /> DESTRUCTION OF WELL:. Well Diameter Approximate Depth l <br /> F •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 -FOR A -GROUT INSPECTION � +. <br /> PRIOR TO GROUTING AN A FINAL_INSPECr ION. <br /> SIGNED TITLE <br /> Ct DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION' ACCEPTED BY ,.� ' DATE <br /> ADDITIONAL COMMENTS: <br /> } PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4LVhDATE y3/1--'7? <br /> , <br /> E H 1426 -Rev.' 1-74 .... h/75 2M <br />