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SAN JOAQ UIN LOCAL HEALTH DISTRICT <br /> F0_R;"OFFICE USE: 1601 E. Hazelton Ave. , StocktonCalif. <br /> Telephone: (209) 466-678i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP FERMIT Permit No. 76-//,6a1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued r _�6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sacs Joaquin Local Health District for a permit to construct <br /> and/or install the work heredescribed. This application is made in compliance with San .Joaquin. <br /> County Ordinance No. 1862 ,&6d the les and 1 ions of the San J aquin Local Health District. <br /> E <br /> JOB ADDRESS/LOCA CENSUS TRACT <br /> Owner's NameC�' { <br /> Phone <br /> �/ k <br /> Address D � ; city <br /> ne <br /> Contractor's Name + License 9 .� Pho ��/ <br /> TYPE OF WORK (Check): NEW 'WELL /7 DEEPEN /` *RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION. PUMP ;REPAIR )& PUMP REPLACEMENT y <br /> Other <br /> r=_ <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 �► <br /> Irrigation Gravel,Pack Depth of Grout Seal + }! <br /> Cathodic Protection Rotary Type.of Grout <br /> Disposal Other Other Information ' ..••...r.+11�+'r.W�� <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. , <br /> PUMP REPLACEMENT: . /; / State Work Done f <br />'PUMP;,.REPAIR! ` '� <br /> DES;TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyiiwith all laws and °regulations of the San Joaquin Local Health District <br /> and the State of Californ.ia' pertaining to or`regulating. well "construction. Within FIFTEEN DAYS r <br /> after completion of my work on a new1well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..wellin.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. ,l <br /> SIGNED TITLE f . <br /> (D PLOT PLAN�ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r' DATE —� F <br /> ADDITIONAL COMMENTS: <br /> PHASE II $P ON P!MIILtKNAL INSPECTION <br /> INSPECTION BY 14. ZDATEVINSPECTION BY ATE y-3-7 <br /> is• <br /> E H 1426 Rev. 1-74 �" h/75 2M <br />