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SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED <br /> FOS,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �/ , Telephone: (20.9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �76- J36o&/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - -? <br /> (Complete In Triplicate) <br /> Application is A'eeby 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 /> � �� too r <br /> Owner's Name _ �-f err D rra Phone <br /> Address rb/ <br /> - �� �-� T��"'" . City Z/�t <br /> Contractor's Namer f p4 License I, �'Phone '�t <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR-1-7—PUMP REPLACEMENT f7 <br /> Other E1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES • PIT PRIVY <br /> SEWAGE DISP SAL FIELD /2c CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF,. WELL CONSTRUCTION SPECIFICATIONS �Q <br /> Industrial Cable Tool Dia. of Well Excavation 4 ,9 <br /> LiDomestic/private Drilled Dia, of Well Casing + v <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> Type -of Grout s clew P1r0A.- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT /7 State Work Done <br /> PUMP .REPAIR: /7 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 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..weli 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 AL INS ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDEjZ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 11 <br /> APPLICATION ACCEPTED BY 2 �6 , <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPEC214 <br /> INSPECTION BY DATE - INSPECTION BY DATE ` <br /> E H 1426 Rev. 1-74 h/75 2M <br />