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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76-Al#9/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &-a y- <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 Ru1qe Ja/}zd Regulationp of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NameG Z tJ!G O ✓�� ic/S/�/ ' Phone <br /> Address ��--�- City <br /> Contractor's Name License - 37�Phonfi�"""og� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/ RECONDITION /� DESTRUCTION <br /> PUMP INST ON / / PUMP REPAIR /� P <br /> Other /�' ��� <br /> 44 V <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 SPECIFICATVONS <br /> Industrial Cable Tool Dia. of Well Excavation 7TH— <br /> ✓Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ply r <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'Donk%'�� <br /> PUMP .REPAIR: % / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter � Approximate Depth -�� <br /> Describe Material and Procedure 5w s . � <br /> lcC. <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 GROU ING AND A FINAL INSPECTION. <br /> SIGNED 222 _ TITLE n <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I F <br /> APPLICATION ACCEPT BY f DATE ' <br /> ADDITIONAL CO <br /> I NSPECTION PHASE III(/FINAL INSPECTIQW <br /> INSPECT DATE s INSPECTION BY ,2 DATE <br /> .aA CO ea <br /> E H 1426 Rev. 1-74 . <br />