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rd <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br /> FOB:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-338'zd' <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued 5�b 76 <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 Ordinande No. 1862. and the, Rules and Regulations of the San.-Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - r.,. CENSUS TRACT <br /> Owner's- Name s phone <br /> Address 5 <br /> _ city .., <br /> Contractor's Name ' License # ' Phone Q <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION f7 DESTRUCTION fes" <br /> t PUMP INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT f <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 /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial Cable Tool Dia-. of Well Excavation �l" <br /> _-V Domestic/private Drilled rr Dia. of Well. Casing <br /> Domestic/public Driven n Gauge of Casing . . .� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ;[ tj.fjlyt 1r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S.P. <br /> PUMP REPLACEMENT: , / state Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: r Well Diameter - f - s t <br /> 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 G OUTING AND A F AL INSP CTIO <br /> SIGNED - TITLE <br /> (DRAW"T PLKN ON REVERSE SID <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY _ _ -DATE .� <br /> ADDITIONAL COMMENTS: <br /> PHASE 1I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION BY DATE <br /> E H 1426' Rev.' 1-74 <br /> 1/75 2m - <br />