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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76.3 1�1Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,f <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 t e Rules and Regulations of the San Joaquin Local Health District. <br /> �.�-F r7 <br /> JOB ADDRESS/LOCATION / ' CENSUS TRACT <br /> Owner's Name (�71 P-I ' / �' Phone / 9 <br /> Address C��5 94 ` �' City <br /> Contractor's Name '�' � �UM�s License <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other <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 Do� A-9 <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 we11"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 .AND A FINAL INSPECTION. <br /> SIGNED 6111,. TITLE - <br /> "�` 'DRAW POT PLAN ON REVERSE SIDE) <br /> PFjOR D A TMENT USE ONLY <br /> PHASE I /K / <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION / PHA III/FINALINSPECTION O <br /> INSPECTION BY V DATE INSPECTION BY DATE _ b <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />