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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOSt4FFICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRi3CTION OR PUMP PERMIT Permit No. 76-,2 81lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued( <br /> ii (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 Regu tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> - it ,. <br /> ri <br /> Owner's Name , Phone <br /> Address �� .� CityGg � <br /> - - ,F <br /> Cantractor's .Name ✓ Licensees Phone ,7 Z11; / <br /> TYPE OF WORK (Check) : NEW WELL /`7 DEEPEN /_7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP� INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT /_7 <br /> Othei <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 <br /> Domestic/private ; Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �' Gravel Pack Depth of Grout Seal Cn <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical i Surface sal Installed B <br /> PUMP INSTALLATION; Contractor <br /> Type' of Pump g.P� �Z2. <br /> :� <br /> PUMP REPLACEMENT: /_1 <br /> , State Work Done <br /> PUM2 '.REPAIR: /_7 State Work Done _ <br /> PE& RUCTION OF WELL: Well: Diameter Approximate Depth <br /> Describe Material and Procedure <br /> IN <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 r <br /> after completion of my work1.on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of theiwell and notify them before putting-the. well in use.. The above <br /> information is true to the-beet-of- my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GI MRd!LaplA INSPECIION. <br /> SIGNED TITLE � <br /> 1� (DRAW PLOT PLAN ON REVERSE SIDE _ -- <br /> ;�, FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 11-L7-761 <br /> ADDITIONAL COMMENTS: iE <br /> PHASE II GROU ` PECTION PHASE jjV/FIN`a INSPEC ION <br /> INSPECTION BY ATE INSPECTION BY DATE Tj <br /> 4 h <br /> 1E H 1426 Rev. 1-74 �I 1-74 2M <br />