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L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO7 <br /> E-:OFFICE USE: �' 1601 E. Hazelton Ave. , Stockton, Calif. t <br /> Telephone: (209) 466-6781 y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76—8 76I� <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 Dis"trict 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. ).8,62- and the Rules arxt ulatio 7 of t e San Joaquin Local Health District <br /> JOB ADDRESS/LOCATIOO�� CENSUS TRACT <br /> Owner's Name` � Phone <br /> Address a-af c3� g�aQ,� City .•• ` <br /> Contractor's Name pf, License # /6a373 Phone ' 66 -f6 2,� <br /> TYPE OF WORK (Check): NEW WELL ' DEEPEN "/ / RECONDITION /_T~ DESTRUCTION ) -w y <br /> PUMP INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT f7 <br /> j <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 <br /> WELL _ <br /> f INTENDED USE ,TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> jIndustrial x Cable Tool, Dia. of Well Excavation <br /> Domestic/private Drilled -Dia, of Well Casing s <br /> F _ Domestic/public Driven .Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal s'Q_ <br /> Cathodic Protection Rotary Type of Grout G#0_yy} 00-&,L- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> P <br /> PUMP INSTALATION: Contractor <br /> jell <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: State Work Done <br /> r <br /> PUMP�REPA�R:,= : - " / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appr imate.. Depth <br /> Describe Material and -Procedure <br /> I hereby agree to comply with all laws and regula lonff of the San Joaquin Local Health District { <br /> and the State of Ca a pertaining to or regulating well'-construction. Within FIFTEEN DAYS. <br /> after completio f my wo k on a new well, I will furnish the San Joaquin Local Health District a 1 <br /> WELL DRILLERS PORT of a well d no them before putting the well "in use. The above <br /> information tr a to e b t I ge and belief, I WILL CALL FOR5A GROUT. INSPECTION - <br /> PRIOR TO GRO TIN FIN <br /> SIGNED TITLE <br /> s <br /> '(DRAWIWT PLAN "ON -SkSE SIDE <br /> FOR DEPARTMENT USE ONLY }I. <br /> PHASE I '6 910- r <br /> APPLICATION ACCE ED BY DATE <br /> ADDITIONAL �COMMLNTS: <br /> PRAR JI G OUT I'SPECTIO PHASE I I INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ,DATE -/dIK ( <br /> E H 1426 Rev. 1-»74 � ' lU �� � <br /> 7H76 <br />