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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFFICAS�Er*�O1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .76' <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued �6-�S"r <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Diattict 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 u les,and R �ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1 . rSUS TRACT <br /> 1 Owner's Name Phone f 3/ IS 2� <br /> Address �„j .[c:� City <br /> F Contractor's Named License /�23 7l Phone ' <br /> E TYPE OF WORK , (Check): NEW WELL '/-7 DEEPEN /7 RECONDITION /Y74KDESTRUCTION f <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT <br /> Other <br /> n ` <br /> � DISTANCE TO NEAREST:" SEPTIC ,TANK f SEWER LINES PIT PRIVY r7`+ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -:PRIVATE DOMESTIC WEL-L=. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE`OF ,WELL ,,. 4_ - ` �1',�., CONSTRUCTION SPECIFICATIONS <br /> i' Industrial ' , Cable,Too1 > Dia. of'Well Excavation <br /> Dome-stir=ford-va-tel '- - Dri led-- - ---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 �. <br /> Geophysical Surface-Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r ` H.P. / - n <br /> f PUMP REPLACEMENT: ,_jr,�T State Work Done <br /> ZW <br /> PUMP :REPAIR: j 7 State Work Done <br /> p2ST RUCTION 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 /> I information M true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ( PRIOR TO G AND,A FAL INSPEPT ION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I / <br /> f APPLICATION ACCEPTED BY -0 � DATE 7i�7s <br /> k ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I T N INSPECTI <br /> INSPECTION BY DATE INSPECTION Br/T DATE <br /> t ;~E H 1426 Rev. 1-74 1-74 2M .. <br />