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CP "^N JOAQUIN LOCAL HEALTH DISTRIC <br /> FOS.OFFICE USE: 16%,�. Hazelton Ave. , Stockton, Cal—.f. <br /> Telephone:_ (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.76,�0��p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / <br /> (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 Joaqui <br /> County Ordinance No. 1862'and <br /> ' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f,(1_ � - CENSUS TRACT <br /> Owner's Name c , ,��g_ Phone _ �( <br /> Address ,z23 Z � , y����pk� City �— <br /> a-- <br /> Contractor's Name License )�'(o 23 23 Phone 3 � <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/-7—PUMP REPLACEMENT <br /> Other E7 <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 Ck <br /> Industrial Cable Tool Dia. of Well Excavation A' <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing (� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ,yam. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor C.G GA <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT /Mate Work Done A.L w a! p <br /> PUMP '.REPAIR: _• . _ / / Sta�e 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 well in use. The above <br /> information is ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROU Op A UNAVINSPECTIO <br /> SIGNED TITLE <br /> OT <br /> (DRAW PLPLAN ON REVERSE SIDE <br /> 'HASE I FOR DEPARTMENT USE ONLY <br /> %PPLICATION ACCEPTED BY DATE <br /> WDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION v PHASE III/FINAL INSPECTION <br /> CNSPECTION BY DATE INSPECTION BY DATE <br /> DUB, -4�<:,�- �, i��L;,,.�.,, Pte.✓ � /9 -7P <br /> E H 1426 Rev. 1-74 �,/7K OM <br />