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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> iM Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-3U IPJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date- Issued <br /> (Complete In Triplicate) <br /> Application is hereby" de to .the San Joaquin Local Health District for a permit to construct <br /> and/or install the work!lherein described. This application is made in compliance with San Joaquin <br /> County Ordinance° o.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> {t�� . <br /> JOB ADDRESS/LOCATION . ,Z j? %= r CENSUS TRACT ' <br /> Owner's Name •�+ - _. . <br /> Phone '15 <br /> IM <br /> Address- City <br /> Contractor's Name3 rV _661�_ Li -� <br /> License # Phone . . <br /> TYPE OF WORK (Check): NEW WELL T DEEPEN /_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' T.,SEWAGE_DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> rPROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indus,trialI/ i Cable Tool Dia. of Well Excavation <br /> _ .►Domestic/p'rivate Drilled Dia. of Well Casing <br /> "^ Domestic/public _DrivenGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -yCathodic Protection Rotary Type of Grout ► `1,� <br /> Disposal ""` Other Other Information " <br /> Geophysical Surface Seal Installed "By: <br /> PUMP 'INSTALLATION: Contractor <br /> Type .of Pu11. mp H.P. <br /> PUMP REPLACEMENT: • /Mi / State Work Done <br /> PUMP REPAIR: '. / State-;iWork Done <br /> DESTRUCTION 6F WELL: Well Diameter Approximate Depth <br /> Describe Material .and Procedure <br /> I herdby 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 ithe 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 /> PRIOR TO GROUTING AND A. ftNAL INSPECTION. <br /> SIGN TITLE �rvy _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . . DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II G `.UT. INSPECTION PHA I N _INSPECTION <br /> ' <br /> INSPECTION BY it DATE _y;.r INSPECTION BY DATE 2 G <br /> ILI <br />;,�_ E H 1426 Rev. 1-74.�- <br />