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7 <br /> .� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> o � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,--76-- <br /> THIS <br /> o. 76'-THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ?-A7--76 .1 <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 /> r <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Namei <br /> Phone ' <br /> Address 2' e � . City <br /> Contractor's Name t. License # Phone 101- <br /> -TYPE OF WORK (Check): NEW WELL DEEPEN '/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP 'INSTALLATION "/ / PUMP REPAIR -/-7 PUMP REPLACEMENT ;/7 <br /> Other 1_7 <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 L <br /> �_ Domestic/private Drilled ' Dia. of Well Casing-!.. _, `A <br /> Domestic/public Drivenr' Gauge of.- Casing <br /> Irrigation k Gravel Pack Depth of�Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout NP�,117' <br /> Disposal s Other g Other Information <br /> Geophysical Surface Seal 'Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ._ !.H. . <br /> PUMP REPLACEMENT: ' /7 ,, State Work Done <br /> PUMP ,REPAIR: <br /> /-7 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 i <br /> WELL. DRILLERS REPORT of the well and notify them before putting the.-wel'l. 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 'ANDA INAL INSPECTION. <br /> SIGNED TITLE <br /> (D PLOT .PLAN ON REVERSE SIDE � <br /> OR DEPARTMENT USE ONLY } <br /> PHASE I E <br /> APPLICATION ACCEPTED BY4% . DATE ' Z� .� <br /> ADDITIONAL COMMENTS: 4I <br /> PHASE II GR INSPECT ION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ TE / .�� INSPECTION BY f DATE <br /> E H 1426 it... 1,76 ),/7q ?M ~i <br />