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VSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77- <br /> j` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> T, <br /> (Complete 77 <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 4 CENSUS TRACT <br /> Owner's Name �� Phone <br /> Address / <br /> y}L City �..^�. G 2 <br /> Contractor's Name License # Phone ,6 1,, A. <br /> t <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN' RECONDITION RECONDITION /_/ DESTRUCTION /-7 `+ <br /> PUMP INSTALLATION / / PUMP REPAIR L-�t PUMP REPLACEMENT /7 <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 WELL J l� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> '>c Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> g <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump =nk eh 1&* H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done ..w. ld <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> iI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land 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 o my knowledge—a d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR `G-ROU ING AND A FINAL I EC 104. <br /> SIGNE TITLE <br /> P OT PLAN ON RSE SIDE) j <br /> FOR DE RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH&$EjjAI/yINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE 2 �I <br /> n rr 11.1-1 ., -_` a 1177 2M <br />