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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: tX 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76_S/b'4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- 30-� <br /> (Complete In Triplicate) <br /> Application � remade to the Scan pp �he( 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 /9 � �C.�-, ,y.,�� ; � $,; CENSUS TRAGI <br /> Owner's Name a. Phone <br /> Address City <br /> City <br /> Contractor's Naim: 2License #pTfj!ZggfPhone <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR 7 PUMP REPLACEMENT /7 <br /> Other /-7 <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 <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRU TI � °p i <br /> C ON OF WELL: Well Diameter Approximate Depth 0V (� <br /> Describe M2terial and Procedure <br /> I hereby agree to comp with all laws and ftgulations 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 AN A FINAL INSUCTION. <br /> SIGNED . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY 1,�.-•� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I)EjX INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />