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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> ITelephone: (209) 466-6781 T Permit No. 7-,9a!_4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI <br /> ..THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2 ?0-76 <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. TResulationsapplication <br /> the SaneJoaquin Localcompliance <br /> HealthSan <br /> District. <br /> County Ordinance No. 1862 and the Rules and g <br /> ill , /aCCENSUS TRACT <br /> JOB ADDRESSILOCATION 3 f <br /> Phone <br /> Owner's Name <br /> City <br /> Address t <br /> License # Phone I <br /> Contractor's Name - <br /> � <br /> E OF WORK (Check) : NEW WELL / I DEEPEN/ I RECONDITION I_7 DESTRUCTION <br /> TYPE ( :per INSTALLATION Ll PUMP REPAIR I I PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOIjISEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> k 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/public _ Driven Gauge of Casing <br /> t <br /> Irrigation Gravel Pack <br /> Depth of Grout^Seal <br /> ? Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> I Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: I I <br /> State Work Done <br /> Approximate Depth _ 6 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure ..._ `&off - -- <br /> I hereby agree, to comply with all laws and regulations of the San Joaquin Local Health District <br /> E 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 <br /> best my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDIRA FINAL INSPECTION. <br /> 4 <br /> SIGNEDy is <br /> �i DRAW PI<; T.' PLAN ON RE ERIE SIDE <br /> FORDEPARTMENT USE ONLY <br /> PHASE I DATED <br /> APPLICATION ACCEPTED BYV <br /> ADDITIONAL COMMENTS: I�. PHAS I NAI, INSPECTION <br /> PHASE II-! GROUT INSPECTION IANSPE-/f3 <br /> INSPECTION BY i�. DATE <br /> INSPECTION BY <br /> 3/76 2M <br /> E H 1426 Rev. 1 74 .Y -- <br />