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SAN JOAQUIN rOCAL�HEALTH DISTRICT <br /> FOR-OFFICE'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 s9 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �6 <br /> r (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 ' - _ --- ---_ —_--_ _ CENSUS TRACT <br /> Owner's Name Phonen —_ <br /> Address vgl, City <br /> Contractor's Name License ! Phone <br /> TYPE. OF WORK (Check):. NEW WELL / DEEPEN /_/ RECONDITION DESTRUCTION /_7 <br /> r- PUMP INSTALION J / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> LAT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p <br /> y SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ry <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well-Excavation o� <br /> Domestic/private Drilled Dia. of Well-Casing 71 <br /> Domestic/public te r_ Driven Gauge-of-Casing ozv <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> �- Other Other Information <br /> a <br /> PUMP INSTALLATION: , Contractor f _. <br /> -Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <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 .pgrtaining 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. <br /> SIGNED i ; TITLE'- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I- ' <br /> APPLICATION ACCEPTED BY DATE i <br /> ADDITIONAL COMMENTS: <br /> P II OUT INSPECTION PHAS I FINAL INSPECT 0 <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTIRG AN'ii FINAL INSPECTI ! <br /> E H 1426 �� r <br />