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iE <br /> II <br /> JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOROFFICE USE: ).,I._,�SAN <br /> � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � 'Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-.517,'4 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> I� (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 Regulatio of the San Joaquin Local Health District. <br /> JOB ADDRESS/hGYATION CENSUS TRACT <br /> it �j 4 <br /> Owner's Na <br /> ` Phone��n`" <br /> Address <br /> Contractor's Name Licens Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> Pb-MP INSTALLATION /—/ PUMP REPAIR PUMP REPLACEMENT /? t <br /> Other <br /> I <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 . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' ' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing CN° <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 <br /> Geophysical II . Surface Seal Installed B : <br /> ii <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: % / State Work Done <br /> ,M <br /> State 'Work Don <br /> PUMP .REPAIR: - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and-Procedure <br /> I hereby agree to comply with all laws anregulations 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 ' 'work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true tolthe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING ,AND FINAL INSPECTION. <br /> k v,cep, TITLE <br /> SIGNED <br /> li DRAW PL'T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. <br /> DATE 3-7 1. <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: Q <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/75 2M <br /> l E H 1426 Rev. 1-74 - <br />