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x <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> F <br /> OR <br /> 7,1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. 77-d d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 '7-17 <br /> (Complete In Triplicate) <br /> Application isiihereby 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 <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> I� <br /> Address ` City <br /> Contractor's Nalene Lice <br /> II nse # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> 1 PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ( , <br /> �I PROPERTY LINE - PRIVATE DOMESTIC WELL ___.___ PUBLIC DOMESTIC WELL "3 <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 1 <br /> Disposal q Other Other Information I <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 /> o zz 6 v ��/ 1 fir O O ??o <br /> j `nES•TRUCTION OF WELL�1Diameter Ap �mafe D <br /> Describe Material an Procedure <br /> I hereby agree to comply ith all laws and Aegulatiohs of the S Joaquin Local Health t` <br /> ind the State oflCalifornia pertaining to or regulating well construction. Within FIFTEEN D&V9 <br /> if ter completion'lof 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 /> RIOR TO GROUTING AND A FIN L INSPECTION <br /> -SIGNED it (��� C__ _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY t <br /> _'RASE I <br /> APPLICATION ACCEPTED BY �'> DATE <br /> 'LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA§ NAL INSPECTION , <br /> INSPECTION BY lj DATE INSPECTION BY DATE <br /> 2M , <br /> E H 1426 Rev. 1-74 ' <br />