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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g,�OfL� <br /> 76 /09/1° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�( <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 /_' CENSUS TRACT <br /> Owner's Name n Phone <br /> Address ` - City <br /> Contractor`',,s Name f",��., r`� �License �� Phone4/ <br /> TYPE OF WORK (Check) : NEW WELL .,g DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/ RIVATE 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 Q) <br /> Domestic/public Driven Gauge of Casing 12— <br /> Irrigation <br /> 2—Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> — <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A'Q + <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 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> j and the State of California taining to or regulating we11 'construction. Within FIFTEEN DAYS <br /> after completion ,o_f my w on anew well, ,I will furnish the San Joaquin Local Health District a . <br /> I. WELL DRILLERS REPORT..ge the well and notify them before putting the .well in use. The above <br /> information ' t ue o the t--af y k. i5)ledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AL INPXQI6.. ! <br /> SIGNED TITLE <br /> DRAW PI. T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY b <br /> PHASE I �/ 76 <br /> APPLICATION ACCEPTED .BY: . ,_ DATE <br /> ADDITIONAL COMMENT§,:-�- .,, , _ <br /> PHASE II GROUT IN PECTION"" �" = fSE`�.I /F A•L INSPECTIO <br /> INSPECTION BY DAA INSPECTION ,BY DATE <br /> 3/76 2M <br /> L E H 1426 v. 1-74 <br />