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f <br /> y SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: E1601 E. Hazelton Ave. , Stockton, Calif. !' <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- � <br /> joy , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-3,57-2,1 <br /> I (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 J aquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION _ �� � CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> 4 <br /> Contractor's Name License # Phone T <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> s; PUMP!MINSTALLATION PUMP REPAIR ./ / = PUMP REPLACEMENT /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 'i 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 l <br /> Disposal I Other Other Information ' <br /> Geophysical I Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'--PUMP REPLACEMENT: / f IlState Work Done <br /> PUMP .REPAIR: /_7 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 Californialpertaining 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 myknowledge and belief. I WILL CAM FOR A GROUT INSPECTION <br /> PRIOR TO G UTING A INAL INSPECTION. <br /> SIGNED TITLE <br /> IM DRAW PL T PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 6� <br /> ADDITIONAL COMMENTS: 1! - <br /> PHAX II G UT.� INSPECTION PHASE TWFININSPECTION <br /> INSPECTION BY :IN DATE INSPECTION BY DATE <br /> Y3/76 2M <br /> v. <br /> E H 1426 Rev,/"l-74 ;� <br />