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•' ; < r;• : SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:� 1601 E. Hazelton Ave. , Stockton, Calif. AN <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77- M9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED Date Isst!ed J :30,7 <br /> (Complete In Triplicate) <br /> �ppl.ication 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 Joaquii <br /> lounty Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . CENSUS TRACT <br /> haner's Name Phone <br /> �ddress4 f f City <br /> :ontractor's Namef. License �� -Phone -2 <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEPEN_/_/ RECONDITION F/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUr9P REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PR'I`TY �— <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER X <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Rotary Type of Grout _ <br /> Disposal Other Other Information �n <br /> Geophysical. Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump _ ' t.t '- rr` �_. � �.. II.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP .REPAIR: W State Work Done <br /> 1 ",ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <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 a <br /> 1ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> _nformati-on is true to the best of;:•my kryowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GLOUTING AND A FINAL <br /> iIGNED 'TITLE <br /> (D G PLO TZAN ON _EVERSE SIDE) _ <br /> t FOR DEPARTMENT USE ONLY <br /> 'HASE I <br /> APPLICATION ACCEPTED BY / � DATE '' d <br /> LDDITIONAL COMMENTS: _ �� <br /> PHASE II GROUT INSPECTION P E _I/ INAL INSPECTION <br /> NSPECTION BY DATE - INSPECTION BY �� DATE _ Li LI j _ <br /> E H 142.6 uP., . 1-7/, n/77 . 2M <br />