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!USAN JOAQUIN LOCAL HEALTH DISTRICT 'TJ <br /> F—OR FFICE USE: I 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76--1a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued6 <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. 18/C1 62�/ <br /> LOCATI and the Rule and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS N ( Go`� --� <br /> / � � � CENSUS TRACT <br /> Owner°s Name .G� r Phone . <br /> Address ��� _ _ g--�c City <br /> Contractors Name �1 �&4 <.^, License #-�Vieel Phone dam- - <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION F7 PUMP REPAIR /-7 PUMP REPLACEMENT / <br /> Other 1-7 <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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ir/ <br /> State Work Donez4&-4d&L 0-1-114 5�7 <br /> PUMP :REPAIR: /7 State Work Done (� <br /> ,2ES,TRUCTION 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 thewellin use.. The above <br /> information is true to the best of my knowledge and belief. I WILL C44L FOR A GROUT INSPECTION <br /> PRIOR TOG UTING FINAL I SPECTION. <br /> SIGNED TITLE a" <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHUM II FINAL INSPECTIOIJ <br /> INSPECTION BY DATE INSPECTION BY" DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />