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,- SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No;. _76. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �� (Complete In Triplicate) <br /> Application is hereby made to the San'Joaquin Local Health District fora permit to construct <br /> tj 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 liOD <br /> CENSUS TRACT ; <br /> Owner's Name <br /> Phone <br /> Address Ild 0 e& ' <br /> City <br /> Contractor's Name License #10 U20 Phone 'gi� pCUs <br /> TYPE OF WORK (Check): NEW WELL � — <br /> / DEEPEN -/-/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR 'E/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled ; Dia. of Well Casing <br /> Domestic/publics ' Driven <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection Rotary Type of Grout I' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / S to 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 HealthlDistrict .., <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 INSPECTION. <br /> r <br /> SIGNED TITLE <br /> D <br /> 4M. PLAN 'ON REWMSE SIDw <br /> DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCE <br /> IV'OR <br /> ADDITIONAL COMMENTS: AR DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1 <br /> (� <br /> ,E`H 1426 Rev, 1-74 <br /> 2.14' <br />