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T- <br /> G SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-13 <br /> THIS PERMIT EXP IRE S "1 YEAR FROM.DATE ISSUED Date Issued 717 <br /> a (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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,. 471:'p.,7. 1NQ• n- �a� CENSUS TRACT <br /> Owner's Name c o Q ,� , �a D'` Phone <br /> Address f� 7 0 City cl Y <br /> Contractor's Name kk License # �J Phone <br /> TYPE OF WORK (Check) : NEW WELL / ./ DEEPEN / % RECONDITION /_/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Y' <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 /> K 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 <br /> Geophysical Surface Seal Installed By_: ' <br /> PUMP INSTALLATION: Contractor ? <br /> Type of Pump rS't�G �r i, /tb H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: X State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations 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 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 /> PRIOR TO GROUTING AND A FINAL I � CTI <br /> SIGNED r•�,�aa�s� �, % TITLE <br /> (DRAW PLOT PLAN ON %RtVERSE SIDE) <br /> j, FOR DEPARTMENT USE ONLY <br /> PHASE I IOU <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHAS jUT/YINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> � r <br /> b17.7 2M <br /> E H 1426 Rev. , 1-74 � � _ � 4 <br />