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m-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0B;,!O�RnCE USE: 160.1 E. Hazelton, Ave.., Stockton, Calif. <br /> Telephone: (209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z-30-76 <br /> (Complete In Triplicate) <br /> . Application p } <br /> pp ., tion ie 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 t <br /> he-Rules and Regulations of the San Joaquin Local Health District.. <br />` JOB ADDRESS/LOCATION ,f/1✓/ c,��,_ ,fsrf� '44W-,---,--CENSUS TRACT <br /> Owner's Name <br /> Phone ' <br /> Address C7 d <br /> City <br /> Contractor's Name ave License Phone y - <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEN 17- RECONDITION ff DESTRUCTION /7 <br /> PUMP INSTALLATION -17 ,.PUMP REPAIR -/� PUMP REPLACEMENT <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 WELL" PUBLIC -DOMESTIC- WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia, of Well Excavation Q <br /> Domestic/private Drilled Dia. of Well Casing R' <br /> Domestic/public Driven Gauge of Casing X) <br /> Itrigation _ Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Groat <br /> Disposal Other • ' Other Information <br /> Geophysical F Surface Seal Installed B <br /> ;PUMP INSTALLATION-0 Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: _ -/),c/ State Work Done.- <br /> 'REPAIR: / / State Work Done <br /> �]ESTRUCTION OF WELL: Well Diameter , <br /> 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.—The above j <br /> 'information is true to the•best of my. knowl and elief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU D FIX INSPECTIO <br /> .SIGNED k -I I <br /> RAW P AN ON REV E SIDE <br /> FOR PAR <br /> PHASE I TMENT USE ONLY <br /> E <br /> APPLICATION.ACCEPTED BY � f DATE <br />..ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />