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n T, <br /> H 6 <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT 1 1 <br /> FOE OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &-z <br /> A-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. 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> I <br /> Owner's Name o GL�, l Q-}� Phone <br /> Address <br /> ? City <br /> j Contractor's Na <br /> m< License # 7t.-Phone '� -76 7�r <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / PRECONDITION / / DESTRUCTION /-7 <br /> PUMP INSLATION PUMP REPAIR /)C/ PUMP REPLACEMENT /? <br /> INSTALLATION —PUMP <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 /> II� Domestic/private Drilled Dia. of Well Casing <br /> >' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of GroutkV <br /> Disposal Other Other Information { <br /> Geophysical 'Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor T M <br /> k, ,Type. of Pump x p H.P,. 1� <br /> h <br /> .. .PUMP REPLACEMENT: / / State .Work Done ` <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> i <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 Districtla® <br /> WELL DRILLERS REPORT of the welland notify them before putting the well in use. The above <br /> information is true to the best of my. Ledge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI . I AND A FINAL I N. <br /> SIGNED . T (1-11ITLE <br /> PL PLAN ON SE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> "t PHASE II GROUT INSP ION PHAS I/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE v Ira <br /> 43/76 2M <br /> �, E H 1426 Rev. 1-74 _... — <br />