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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFF'ICE USE: 'i. / 1601 E. Hazelton Ave. , Stockton Calif. <br /> III/// <br /> Telephone: <br /> (209) 466 <br /> APPLICATION FOR WELL CONSTRUCTION 6OR1PUMP PERMIT Permit No. 76-� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 33 <br /> i� (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constr <br /> and/or:install .the work herein described. This application is made in compliance with Su <br /> County'Ordi,nance No.' -1862 and the Rules and Regulations of the anJoaquin <br /> San Joaquin Local Health District. f <br /> w <br /> JOB ADDRESS/LOCATION_ 1,17 <br /> _ CENSUS -TRACT <br /> Owner's Name F <br /> Phone <br /> Address - f <br /> City <br /> Contractor's Namef' f . <br /> t <br /> License Phone <br /> TYPE_OF WORK (Check):A . NEW WELL `/7_ DEEPEN /_7 RECONDITION /_7 DESTRUCTION f 7 <br /> �- ---PRIMP-INSTALLATION <br /> Other PUMP REPAIR Jam/ PUMP REPLACEMENT �f <br /> /j <br /> i a <br /> DISTANCE .......TO NEAREST: }SEPTIC TANK SEWER LINES <br /> :SEWAGE DISPOSAL FIELD fPIT PRIVY <br /> u CESSPOOW SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TIPS OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of We11,Excavation <br /> Domestic/private Drilled <br />. ,_„Domestic Dia. of Well Casing <br /> /Public - .Driven <br /> Irrigation - . �:=,�Gaugetiof�Casing <br /> '1 'Gravel,Pack:�. Depth of Grout Seal <br /> Cathodic Protection 0Rotary Type of Grout <br /> . <br /> osal Other Other Information <br /> •' Geophysical' _'wi � ~` .Surface Seal Installed B � <br />`PUMP INSTALLATION* Contractor `� <br /> *� dn1 <br /> Type of Pump ; <br /> H.p. <br /> PUMP REPLACEMENT: L --/ State Work Done <br /> PUMP'REPAIR' R = 7-- State Work Donee <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedures APProximate .pepth <br /> �� <br /> I hereby agree to comply with all laws and regctlation$ of the. San Joaquin Local;-Health. District y <br /> and -the State of California pertaining to or regulating well`constructi.on. 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 Weil 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 FO 'A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INS ECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: 4 DATE ^�',., <br /> q PHASE II GROUT INSPECTION <br /> INSPECTION BY P SE III/FINAL INSPECTION <br /> DATE INSPECTION BY DATE <br /> E H 1426 Rev. -1-74 ° <br />