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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. 209 <br /> ( ) 466--678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued76 <br /> X76 <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 and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> { CENSUS TRACT <br /> Owner's Name <br /> Phone 4 <br /> Address <br /> City <br /> L;i: <br /> Contractor's Name OIL— License )-3 Phone - . <br /> TYPE OF WORK (Check) : NEW WELL g DEEPEN _ <br /> �r /7 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION,; PUMP REPAIR/� PUMP REPLACEMENT f-7 , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES /00 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .f -jl ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELT, '.:&„ PUBLIC DOMESTIC WELL <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> it.:; Domestic/private Drilled a Dia. of Well Casing g <br /> Domestic Driven--" Gauge of Casing. , <br /> Irrigation Gravel Pack Depth 'of-Grout Seal <br /> 'Cathodic Protection Rotary470� Type of Grout <br /> —Disposal ' � Other .,.. <br /> ,�- Other Information ' ' <br /> Geophysical Surface Seal Installed 'By: _ <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: . <br /> State Work Done <br /> PUMP .REPAIR. / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth -- <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 t <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 CALL FOR A GROUT INSPECTION <br />?RIOR TO G TIN AND A AL'INSP ION. <br /> SIGNED <br /> TITLE <br /> DRAW ,PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYAn � <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II,GROUT I PECTION { <br /> PHAM IPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY/��7� DATE a <br /> E H IA26 <br />