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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _: D-77 <br /> (Complete In Triplicate) <br /> Application is hereby made to ,the San Joaquin Local HehDistriae ,inrca ppermit <br /> to consanuJoaquin <br /> and-/or install the work herein described. This application <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCA ON <br /> ' Phone <br /> Owner's Name <br /> City � + <br /> Address <br /> ' Name License #K6 Phone 3 4 r 3� <br /> Contractor's <br /> STRUCTION 1-T <br /> TYPE OF WORK (Check) : NEW .WELL /� DEEPEN / RECONDITION / REREPLACEMENT- R <br /> PUMP INSTALLATION/ / PUMP REPAIR /x�� UMP <br /> Other "/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYi. _ <br /> ----SEWAGE.DISPOSAL,FI-ELD - -�• CESSPOOL/SEEPAGE P_IT, OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED <br /> 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 /> Information <br /> Disposal , Other Other <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION:- ., 'Contractor <br /> , --Type of Pump <br /> PUMP REPI;ACEMENT: - &/—S-fate Work-Done <br /> ,.P-UMP:.REPAIR: r;± ,( State Work Done <br /> Appr ximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> k I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 1 and the State of Californialpertaining to or regulating well'construc`tion. Within FIFTEEN DAYS <br /> r after completion of my worklon a new well, I will furnish the San Joaquin Local Health District a <br /> notify them before putting the ,well in use. The above. <br /> WELL DRILLERS REPORT of the well and <br /> information 's true to the best of my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G IN AND A AL INSPECT ON. TITLE <br /> SIGNER <br /> D W..P T' PLAN 'ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,f} DATE <br /> APPLICATION ACCEPTED BY U�- <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION ~ . INSPECTION BY �. �3 DATE s�/����7 <br /> INSPECTION BY DATE <br /> k <br /> f 3/76 214 <br /> E H 1426 Rev. 1-74 <br />