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V" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued1 x-76 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `yf ,I� e� � CENSUS TRACT <br /> Owner's Name ' Phone <br /> 01 <br /> Address V a �.-� City <br /> Contractor's Na License # 21—'fhone �- to / <br /> TYPE OF WORK (Check): NEW WELL,17 DEEPEN -/'7 RECONDITION /-7 DESTRUCTION / 7 <br /> PUMP INSTALLATION /% PUMP REPAIR/5f PUMP REPLACEMENT % 7 <br /> /� } <br /> Other � .; . <br /> y_x"_'. <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 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 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor e ski <br /> Type of Pump T�r <� H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP :REPAIR: _/X7 State Work Done <br /> I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND-A FINAL INStMIO ,. �h <br /> SIGNED .uT <br /> iTLE <br /> RAW YLLOTPLAN ON ERSE SIDE <br /> PHASE I <br /> FOR EPARTMENT USE ONLY <br /> . <br /> APPLICATION ACCEPTED BY DATE ) <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTIOjq PHASE ITJfFINAL INSPECTION ` <br /> INSPECTION BY DATE INSPECTION BY <br /> E R 1426 Rev. 1-74 r' 4/75 2M <br />