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G� 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 /> 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 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. 16 d the Rules atid Regulations of t San Joaquin Local Health District. <br /> va <br /> JOB ADDRESS/LOC ON CJ GJ CENSUS TRACT - <br /> Owner's NamePhone 7 <br /> Address ! ✓ Z2 Cit <br /> Contractor's Name�,-L� �vM S License #1/6:)`373Phone4&7d�e'— <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION L7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR I-7 PUMP REPLACEMENT <br /> Other i-1 — <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 TYP9, OF WELL CONSTRUCTION SPECIFICAT <br /> Industrial ' Cable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled . Dia.-of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . State Work-Done /)Z <br /> PUMP ,REPAIR: <br /> /-7 State Work Done <br /> 2ES1RUCTION 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 <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED ,- TITLE <br /> DRAW PLOT PLAN ON REVERSE SIBE_� <br /> FOR DEPARTMENT USE ONLY ---- <br /> PHASE I / <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT itSPECTION PHASff III FINAL INSPECTIO <br /> INSPECTION BY DATE � INSPECTION BY DATE / <br /> H 1426 Rev. 1-74 ri <br /> L`7-5.-:.2M <br />