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CLff SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 431cJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ..OB ADDRESS/LOCATION _t, tt CENSUS TRACT <br /> wner's Name ��/�� i�Ct✓�`!�s Phone ,37 <br /> Address City �o64 <br /> _ontractor's Name � License Phone 4/- <br /> 'YPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR ,/—/ PUMP REPLACEMENT /_ <br /> Other <br /> ,_iISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL Za6_/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 /p " C <br /> Domestic/public Driven Gauge -of Casing fp <br /> - Irrigation Gravel Pack Depth of Grout Seal Q c <br /> Cathodic Protection _ Rotary Type of Grout ��� b` <br /> Disposal Other Other Information <br /> Geophysical / Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. f i <br /> "UMP REPLACEMENT: / / State Work Done <br /> 'PUMP .REPAIR: / / State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L 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 /> WELL DRILLERS REPORT of ll and notify them before putting the well in use. The above <br /> information is true t the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -PRIOR TO GRO N INAL N I N. <br /> SIGNED 11pTITLE <br /> !,(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FORDEPAYTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ..ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />