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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,0FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3--?- -7b <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 JDF `^", �� CENSUS TRACT <br /> I <br /> Owner's Name - �Ar Phone <br /> Address c�t <br /> City <br /> Contractor's Name C � License Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /-7 RECONDITION /-7 DESTRUCTIO14 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMEN /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALFIELD 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 Lr <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: /7 State Work Done <br /> ,SES TRUCTION OF WELL: Well Diameter Approxftmate Depth <br /> j Describ Material and Procedure > <br /> { Y� , J <br /> I herebyagree to comply g p y wi h <br /> t all laws and regulations oV the San Jo q n cal alt 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 true to the, best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING MjVAANAL INSPECTION. <br /> SIGNED c � � . TITLE <br /> (QRAWFLOT` PLAN ON REVERSE SIDE <br /> ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G I PHASE III INAL INSPECTION <br /> INSPECTION BY D INSPECTION BY ✓, DATE .7 - - 6 <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />