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TM <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76- /0 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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. 186.2 and the Rules and. Regulations of the San -Joaquin Local Health District. <br />.SOB ADDRESS/LOCATION53_ - CENSUS TRACT <br /> Owner's Name Phone 3 _'/2 <br /> Address . <br /> Citya� <br /> Contractor's Name, <br /> License 90. Phone�ifi � :5"� <br /> ry <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / 7 RECONDITION /_7 . DESTRUCTION /_7 i <br /> PUMP INSTALLATION / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> x Other r_7 <br /> - 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />��Domestic/private <br /> Industrial le Tool Dia. of Well Excavatio <br /> Drilled Dia. of Well Casing re ! <br /> Domestic/public Driven f - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - y <br /> Cathodic Protection Rotary Type of Grout <br /> - Disposal Other Other Information " i <br /> Geophysical Surface Seal Installed-B <br /> PUMP TINSTAZ-L�I'PION o C _ u <br /> ontractor ��.., - } . <br /> Type of Pumper-, H.P. <br /> PUMP REPLACEMENT: . `` <br /> / /._Slate'-Work Done � <br /> PUMP .REPAIR: b/%c`State Work,.Done - <br />)ES!TRUCTION OF WELL: Well Diameter <br /> ZQ Approximate Depth " <br /> t Describe Material 'and Procedure , <br /> L hereby agree to comp l with all lavid- afid.; egulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> Ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a i <br /> 4ELL DRILLERS REPORT of the well and notify them before putting..the..well. in.use.. . .The above <br /> Lnformation is true to the-best-of my.knowledge and`�,belief. sIWILL CALL FOR A GROUT INSPECTION ! <br />'RIOR TO GR TI A FIN I PE ION. I - # <br /> SIGNED TITLE ! <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />?RASE I �� ., } <br /> iiPPLICATION ACCEPTED BY DATE d #j <br /> 1DDITIONAL COMMENTS: P { <br /> PHASE II GROJT INSPECTIONPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE f 4 .... ____.INSPECTION,,BY _ DATE <br /> E H 1426 Rev. 1-74 M <br />