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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.'OFFICE USE: �' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-66.3 X' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 730_ 6 <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 Ordinance No. 1862 and the <br /> Rules and Regulations -of the San Joaquin Local Health District. <br /> Dj <br /> JOB ADDRESS/LOCATION l to d (. _ CENSUS TRACT <br /> Owner's Name Phone� -���� <br /> Address City <br /> Contractor s Name <br /> License �f�0 Phone <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL/_7DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT fT <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 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 <br /> Disposal Other Other Information QD <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 67 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> l <br /> PUMP .REPAIR: / / 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 LocaFH-e-alth District <br /> and the State of California pertaining to or regulating well'construction. Wiin 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 CAJI, FOR A GROUT INSPECTION <br /> PRIOR TOOUTI D FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW L T PLAN ON RE RSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I DATE t '� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION PHASE I FINA INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />