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SAN JOAQUIN ,LOCAL HEALTH DISTRICT <br /> F0_K70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76__5-_201&7 <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 �2 9_3 7 6 S, r CENSUS TRACT <br /> Owner!s Name Phone <br /> Addresszz City <br /> Contractor's Name LicensePhone -_ <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION % f <br /> j DESTRUCTION f �i <br /> PUMP INSTALLATION /� YUMP RE AIR -/� P REPLACEMEN f 7 <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 (4` <br /> Domestic/private Drilled Dia. of Well Casing .p � <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 / / State Work Done <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 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 is true to the-best -of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT'ING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE_SIDE <br /> - FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION' ACCEPTED BY -�C�_44DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHA. III _ZNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE " 6�' 72y� <br /> E H 1426 Rev.�1-74 _ . L/75-- <br />