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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0Fi7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76--i3341-,' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 A!Z-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/LOCATIONCENSUS TRACT <br /> Owner's Name �' -.�1 - f���.ti. Phone <br /> Address / , _ ~ .� City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL ;;��-- DEEPEN/7 RECONDITION /�7� DESTRUCTION /-7 <br /> PUMP INSTALLATION I� PUMP REPAIR/�PUMP REPLACEMENT /? <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 t <br /> Industrial Cable Tool Dia. of Well Excavation 2 v 61 <br /> Domestic/private Drilled Dia. of Well Casing 12 Q <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 /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> info on tru t :t b st o MY knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIO TO,, G A I PECTION. <br /> SIGNED ' TITLE _ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i �/ 7 <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: - 43 <br /> PHASE II GROUT INSPECTION PHKSE- IlnVFZNAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE 2 S' <br /> h/'l <br /> E H 1426 Rev. 1-74 5 <br />