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C P "N JOAQUIN LOCAL HEALTH DISTRIC' <br /> F_06- FICE USE: 160%.,2. Hazelton Ave. , Stockton, Cam. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.76-/0�( <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,6�_7L <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (tet/. � �a.�J73� /a4_/ - � Q� CENSUS TRACT <br /> Owner's Name _/ � <br /> ' . ,-,,; r Phone �}l ,P-l? <br /> Address Z 3 23 Z City <br /> Contractor's Name � License j Phone .3(� <br /> TYPE OF WORK (Check) : NEW WELL /_/ DEEPEN/7 RECONDITION /7 DESTRUCTION /7 <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 PUBLICDOMEECSTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation X <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical `� n ate. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ADD G C R �z <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / <br /> / �tate Work Done .�,[,L &-/-,I ,f�yn� � ��' �_o�✓--- <br /> _ - <br /> PUMP .REPAIR: / / State Work Done (� <br /> 3ES•TRUCTION 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 /> 4ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROU ' A F N INSPECTIO . <br /> 3IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 'RASE I FOR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED BY _r. / DATE /D <br /> iDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> :NSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />