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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FOE-OTFICE USE:,, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueNEC 2 $ �19Yp <br /> (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 ,7�75 �•I��t \.� _ CENSUS TRACT <br /> Owner's Name ] l _ Phone tS <br /> Address �o City _ <br /> Contractor s Name 911k-- R <br /> License # Sf3 Phone 'S�g - <br /> TYPE <br /> OF WORK (Check): NEW WELL . DEEPEN/ / RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR f PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,p. SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD 419,W 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 17 <br /> Domestic/private �}� - Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4�aj <br /> Irrigation Gravel Pack Depth of Grout Seal < <br /> Cathodic Protection Rotary Type of Grout Y <br /> t Disposal Other Other Information <br /> ` Geophysical . . Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor fes/ <br /> Type of Pump �-r - H.P. <br /> PUMP REPLACEMENT: / / State Work none <br /> P.UMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION 'OF WELL: Well Diameter ` <br /> Describe Material and Procedure <br /> 'n <br /> I .hereby agree to comply with all laws and regulations of the San Joaquin Local Health Di®rtfct <br /> and the State. of California pertaining to or regulating well-construction. Within FIFTERN DA,XNS. <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 INSPECTi <br /> PRIOR GROUT AND IN SPECTION. <br /> SIGNED TITLE <br /> D W PLAN ON REVERSE SIDE . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL f;E}MM$NTS: _ <br /> k PRASE II GROUT !NSP CTION P�iA E I INAL INSP� TIOZi <br /> INSPECTION IiY � DATE --- e-- INSPECTION BY DATE <br /> 316E 8 1426 Rev. 14,74 - <br />