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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•�OFFICE USE: V/1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-�/3 G) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - o__79 <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 e' CENSUS TRACT <br /> Owner t s Name Phone rJ& <br /> Address oy 2 City .� <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/7 RECONDITION /7 DESTRUCTIONT <br /> PUMP INSTALLATION /7 PUip REPAIR /7 PUMP REPLACEMENT /7 <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERI <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 'ttv <br /> 1 <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 la <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done f' <br /> P�:REQ: L7 State Work Done / • <br /> ,DESTRUCTION OF-WELL: Well Diameter �.-� � 010Approximate Depth �. <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations oV the San Jo quin 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 tot -best.of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND K FI AL .•INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY E <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A0.9. _ DATE y .. Ax <br /> E H 1426 Rev. 1-74 1-74 2M A <br />