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V' <br /> . .. .. ��� SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLI�ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76�/a�Fsl'� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 D-.a•S_2 <br /> I (Complete In Triplicate) <br /> f 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. 1$62 and the Rules Regulations of the San Joaquin Local Health District.' <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone 3� � <br /> Address <br /> City <br /> Contractor's Name License # Phone <br /> it <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN -/—/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT! <br /> Other <br /> DISTANCE.TO,.NEAREST: SEPTIC :TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public -*- 'Driven Gauge of, Casing- f �' <br /> Irrigation _ Gravel Pack " `.Depth of`'Grout Seal <br /> Cathodic Protection ` ' Rotary Type of Grout <br /> Di posal t" + Other Other Information f <br /> Geophysical `z Surface Seal Installed By: } <br /> PUMP INSTALLATION. Contractor�/ . a <br /> Type of Pump H.P_ <br /> PUMP REPLACEMENT <br /> State Work Done ..a- dW <br /> PUMP .REPAIR: /7 State Work Done . <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth � <br /> Describe Material and Procedure <br /> I hereby agree',. to comply wiW 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 Districta � <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true the best of my..knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO OUTING B FI AL of <br /> ION. <br /> SIGNED TITLE"(DMW POT PLAN 'ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT. USE ONLY <br /> APPLICATION ACCEPTED BY _. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE i GROUT INSPECTION PHASE U FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ✓/- 7- <br /> E H 1426 Rev. 1-74 376 2M <br />