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f <br /> -` SAN JOAQUIN LOCAL HEALTH- DISTRICT i <br /> CO& OFFICE 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 Issued �`2 <br /> (J 7 <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 /> Coup y Ordinance No. 3862 and � u 1� and e tions of the San Joaquin L cal,V th District. <br /> �� Ale <br /> JOB DRESS/LOCATION rz � moi'' �— -. CENSUS TRACT <br /> Owner's Name -(��.C.Cp4� L �_ �' Phone �r9 <br /> Address r�/42� �- City / <br /> Contractor's Name d License # ���d Phone acs <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 7", 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 4 Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing 4 <br />-- �-�---irrigation �-- Grave1-Pack- — Dep-th--of-Grout-Seal --:` <br /> __ - -C_athodic_Pz:ote.ctio.n — Rotary '•' ' _ y -TXPe_of, Grout-- Q <br /> Disposal Other Other Information <br /> Geophysical;"`x Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. <br /> TyPe�of Pump H.P. <br /> PUMP REPLACEMENT: / / State •Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth syF <br /> _ Describe Material and Procedure <br /> I <br /> j 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 /> WELLIDRILLERS 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 RUT NG MD A FINAL INSPECTION. <br /> SIGNED TITLE ' <br />'F (DRAW PLOT PLAN ON REVERSE SIDE) <br /> "FOR"DEPARTMENT-USE ONLY <br /> PHASE I <br /> p APPLICATION ACCEPTED 'BY DATE <br /> ADDITIONAL COMMENTS: 3 <br /> PHAM II G (ut_IN-.._ �,. S.E�III./-FINAL INSPECTION <br /> f INSPECTION. BY DATE INSPECTION By-_,& DATE <br /> 4 <br /> 3X17: `.2W <br />