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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICErUS :,a 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � 7.6/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE' ISSUED -Date Issued X76' <br />} (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i 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 ! r <br /> r � _� NSUS TRACT <br /> Owner's Name Phone <br /> i Address Cit <br /> I Contractor's Name License <br /> i <br /> TYPE OF WORK (Check) : NEW WELL U�DEEPEN / / RECONDITION /_/ - DESTRUCTION /_7 <br /> i PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 1_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 L CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation 4 p! <br /> omestic/private°`, Drilled Dia. of Well Casing I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .' z Gravel Pack Depth of Grout 5eaf <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other <br /> •. h <br /> Informaion.;-Geophysical Surface Seal Instal <br /> ed By:'tInstalled <br /> .. <br /> PUMP INSTALLATION: '"Contractor <br /> \Type of Pump - H.P. <br /> PUMP REPLACE <br /> MENT: �'% / S tate Work Done <br /> PUMP -REPAIR: _ _ a <br /> State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApproximate 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 we11 "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will.rfurnish -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 m knowledge and belief.- I WILL C L FO /X,'.GROUT INSPECTION <br /> PRIOR TO GROUTI A FhJAL INS P ION <br /> SIGNED # y <br /> TITLE t <br /> DRAW P PLAN 'ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Jib �� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> . E H 1426 Rev. 1-74 376 2M <br />