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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk 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 1 YEAR FROM DATE ISSUED Date Issued ll,x1 -77 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Ordin c,� No. 18fa2 an the les aid, Reg ions of he San Joaquin Local Health District. <br /> JOB ADD S OCATION „Jx2a,L CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address D -� City <br /> Contractor's Name License j Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/ / RECONDITION / / DESTRUCTION /_7PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 10 @ SEW R-LINES PIT PRIVY ti <br /> SEWAGE DISPOSAL FIELD/067 ' CESSPOOL/SEEPAGE PIT OTHER � . <br /> PROPERTY LINE -- PRIVA E DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of Well Excavation <br /> ,::;t_ Domestic/private Drilled Dia. of Well Casing 0 <br /> Domestic/public Driven Gauge of Casing _:11 \l� <br /> Irrigation Gravel Pack Depth of Grout Seal Lro <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed_ By:_______ <br /> PUMP INSTALLATION: Contractor W10 Ar <br /> 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work'Done ° <br /> PUMP REPAIR-:-- / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter $: ApproximRate Depth <br /> Describe Material and Procedure <br /> I <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 G TING AN A FINAL INSPECTION. j. <br /> SIGNED ,�� TITLE <br /> (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 PHASE III/FINAL INSPECTION/ <br /> INSPECTION BY �_6� T DATE S 7 INSPECTION BY DATE 2-'3 V <br /> 1177 2M <br /> H 117 f] Rosr. 1_7d ' <br />