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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOh:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209),1466-6781 <br /> ,71 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76�j36tr/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j­/ <br /> 7� <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 Noi 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONX21 �C2�rl'1 `2 CENSUS TRACT <br /> Owner's Name _ -c7W/ e4/C CF Phone <br /> Address <br /> • -�- t City Q �1 <br /> Contractor's Name �L / � 5,/�!� License i _4'Thone� �-- 9�~. <br /> A <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN '/ RECONDITION /7 DESTRUCTION /� <br /> PUMP INSTALLATION / / UNP REPAIR -1-7-PUMP REPLACEMENT /? <br /> Other %/ <br /> DISTANCE TO NEAREST:- SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL 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-Wel7l EXoavation <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__Bv By: <br /> PUMP-INSTALLATION: Contractor <br /> Type .of Pump H.P.", <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,REPAIR: A <br /> _ / / 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' conipleton 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 FORA GROUT INSPECTION <br /> PRIOR TO G UTIN AND A J!INAL INSPECTION. i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> �,, <br /> APPLICATION ACCEPTED BY _ ___.. ..._ DATE "y 3'-��-.1L <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE AI;IFINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BX DATE zzl= <br /> I <br /> E H 1426 Rev. 1-74 r' " 1t 72M <br />