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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrOFF_ICE USE:� - 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 <br /> �/ication <br /> / 3S THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -bra/ <br /> (Complete In Triplicate) <br /> App 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 o._,1862 and the. Rules and Re lations of the San Joaquiq Local Healt District. <br /> JOB ADDRESS/LOCATION > CENSUS <br /> TRACT 1t a� <br /> Owner's Name Phone <br /> Address Cit , <br /> Contractor's Name�a License Ot Phone V <br /> TYPE OF WORK (Check): NEW WELL /? ' DEEPEN _/-7 RECONDITION /-7 DESTRUCTION f <br /> PUMP INSTALLATION / MP REPAIR 17 PUMP REPLACEMENT /7 <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 -.,, I Cable Tool Dia. of Well Excavation <br /> Domestic/privae. , Drilled , Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of�Grout Seal <br /> Cathodic Protection Rotary , J' Type of Grout <br /> Disposal. Other � Other Information <br /> Geophysical r ace Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Done . <br /> ES-TRUCTION OF WELL: Well Diameter ' <br /> _ 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 /> WE L DRILLERS REPORT of the well and notify them before putting the- well in-use.. The above <br /> in * tion is true to the est knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTING AND A F AL N. <br /> SIGNED zTITLE <br /> -' W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATibW JACCEPTED BYDATE '`f -7 d <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DAT7 INSPECTION BY DATE <br /> t E H 1426 Rev. 1-74 <br /> 1-74 2M <br />