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SAN JOAQUIN LOCALSHEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APkICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7yl 78a� <br /> 76-A066A" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-3�7_� <br /> (Complete In Triplicate) <br /> Application ie hereby made tti the Sats Joaquin Local 11ealth 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. d <br />_JOB ADDRESS/LOCATION {.!/ 2— CENSUS TRACT ; <br /> Owner's Name Phone ' 6 <br />'Address <br /> City <br />:Contract6r's Name � ' <br /> _ icense # Phone <br /> 'PE_OF WORK (Check}: NEW WELL '/ EEPEN /' .:. RECONDITION'/. DESTRUCTION /.f <br /> PUDU;_INSTALLATION 17 TPUNP REPAIR'/---7)7UMP REPLACEMENT /7_ q <br /> ray .:.r- +-!^ -•.,. <br /> —Other-r-- <br /> �. <br /> DISTANCE TOiNEAREST: SEPTIC TANKSEWER -LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL`' � PUBLIC DOMESTIC WELL'S ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. a <br /> able Tool Dia. of Well Excavation . <br /> • :.Industrial ,• , <br /> Domestic/private Drilled Dia. of Well Casing � <br /> r= Domestic/publicDriven Gauge of, Casing _ { <br /> Irrigation - Gravel Pack- Depth ofi Grout Seal + j <br /> y..... <br /> Cat}iodic Protection Rotary. Type of Grout <br /> Disposal Other Other In ...�" <br /> Geophysical . Surface Seal Installed By:- <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: . / / State Work Done - <br /> PUMP .REPAIR: / / State Work Done <br />)ES-TRUCTION OF WELL: Well Diameter """'" '`Approximate Depth <br /> Describe Material and Procedure IA <br /> I hereby agree to comply with all ]laws and regulations of the San Joaquin- Local Health District 9 <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..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 GROUTING `AND A FINAL INSPECTION. G <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION' ACCEPTED BY DATE ICS: 7"?G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAV�.,)I11jXjVAL INSPECTION <br /> CNSPECTION BY DATE. INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />