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GL, / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> gOF�'pFgICE USE: 0 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />{ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-77/V <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED mate issued <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/ I CENSUS TRACT <br /> San Joaquin Local Health District. <br /> ' <br /> JOB ADDRESS/LOCATION cy 1-.eft 1 KI -- <br /> //'' f ` <br /> Phone ' _ 77-52 <br /> .1 Owner's Name �✓` Lir Gt l C <br /> Address. S ?l City <br /> Contractor's Name - �' ; License Phone ' <br /> TYPE OF WORK (Check): NEW WELL I�T DEEPEN '/7 RECONDITION DESTRUCTIOId� <br /> 4 PLW. INSTALLATION I I PUMP REPAIR I� PUMP REPLACEMEN I T <br /> s Other <br /> DISTANCE TO NEAREST: SEPTIC TANK sSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD u.- CESSPOOL/SEEPAGE PIT OTHER , (� <br /> s PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL' C] <br /> : INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of Well.Excavation t <br /> . Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary - Type of Grout <br /> Disposal Other 1 -Other Information ' ' <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type. .of Pump H.P. i <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> � : r . , <br /> PUNP .REPAIR: / % ` State Work Done <br /> f <br /> if ' [— <br /> DESTRUCTION OF WELL: Well Diameter A proximate Depth J <br /> Describe tenial and 1Procedure <br /> I 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 <br /> WELL DRILLERS RE-PORT--of-the;well-9and-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 TOG-ROUTING' Afia A JINATINSPECTION. , # <br /> SIGNED r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DAT 'I� <br /> ADDITIONAL COMMENTS: <br /> P S g <br /> PHASE II GROUT INSPECTION I3 FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE l0 <br />