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r" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76.,pg7p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _Za-3-26 <br /> 1 <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 Rules a d Regulation o the San Joaquin Local Health District. <br /> ��s <br /> JOB ADDRESS/LOCATION �7�� �'�'�- CENSUS TRACT <br /> Owner's Name ) Phone <br /> / <br /> Address / 76--� GCS City�G-s <br /> Contractor's Name ✓ License 4���'6v�' Phone / <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <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 U� <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 <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. S <br /> PUMP REPLACEMENT: / State Work Done a'ccY <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 Local Health District <br /> and the State of California pertaining 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 my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GPUTING D INAL INSECTJON. <br /> SIGNEDTITLE2L� 7`- -177, 1 <br /> DRAW PIS T PLAN ON RE RSE SIDE — <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS IT, GROUT INSPECTION PHASE I ,I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Al D TE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />