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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: 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 /> TMS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 /> X <br /> JOB ADDRESS/LOCATION d �© CENSUS TRACT <br /> Owner's Name Phone 33 V D �- <br />� Address �` _.._ <br /> city ' <br /> pp Contractor',e Name <br /> License Phone <br /> or <br /> f' <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN/_7 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 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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> I Geophysical Surface Seal Installed 'B : <br /> PUMP' INSTALLATION: Contractor <br /> k Type of Pump H.P. <br /> F _ ' <br /> PUMP State Work Done Q <br /> PUMPiREPAIR:-X /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 /> i 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 G OUTING AND A FINAL INSP CTION. <br />( SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I '` <br /> FOR DEPARTMENT USE ONLY <br /> �j <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: .- <br /> PHASE If GROUT INSPECTION PHASE I I F AL YNSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r t. -7r mor <br />