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_ _ T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FoRtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pexmit No. 76-N�7 . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ? <br /> t (Complete In Triplicate) <br /> Application"is hereby'made to the San Joaquin Local Health Diattict 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 Locail Health District. -- i <br /> ' A <br /> JOB ADDRESS/LOCATION �a SUS TRAC <br /> Owner's.Name Phone `Z' - <br /> Address <br /> _ MAA�q ! k1 9 city � <br /> Contractor's Name - License #210() .�' hone4l,(6r <br /> .s [ ! !!l <br /> PUMP INSTALLATION -- <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/? RECONDITION / Y DESTRUCTION /7 - <br /> I�I PUMP REPAIR /� PUMP REPLACEMENT 1 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,2,S Cir 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 \j <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public-! Driven Gauge of Casing <br /> Irrigation " '" _ Gravel Pack Depth of Grout Seal <br /> Cathodic' Protection _ y[ Rotary Type of Grout <br /> Disposal �"> Other Other Information ' <br /> Geophysical � - Surface Seal Installed B <br /> s' <br /> r---.--�,�r <br /> PUH' YNSTALLATION: Contractor it <br /> ' Type of Pump <br /> t� r B.P. <br /> PUMP REPLACEMENT: <br /> __/ 7 State Work Done <br /> ..- - . <br /> PUMP-:REPAIR:­-- 7--�--State-W - - <br /> - Work. Done��_ <br /> ES;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 /> 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 R'A 'GROUT INSPECTION <br /> PRIOR TO C2WVTINr. ANDAF ECT ION. <br /> SIGNED ' + w <br /> -- - _f TIT_LE� r <br /> (DRAW PLOTPLANONrREVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> .. <br /> APPLICATION ACCEPTED BY .t - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHAU 4IIF NAL INSPE "ION <br /> INSPECTION BY DATE INSPECTION BY r DATE <br /> F f <br /> E H 1426 Rev. 1-74 1-74 2m <br />