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/ SAN JOAQUIN LOdl HEALTH DISTRICT <br /> 7970FFICE USE: f/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> !Y� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued /_J _;74 <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 Z,.7 _ l <br /> L 0 SUS TRACT <br /> Owner's Name phone , ?367- „-V?4 <br /> Address City , <br /> Contractor's Name ,License # Phone 622 <br /> TYPE OF WORK (Check): NEW WELL /P' DEEPEN/7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY'' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL :-Af PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing � .ol�t,sfzc� <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth+of' Grout Seal <br /> Cathodic Protection V- Rotary Type of�Grout <br /> Disposal - Other F Other Information — <br /> Geophysical <br /> P t Surface Seal Installed 'B <br /> PUMP INSTALLATION- Contractor <br />' Type of Pump H.P. , <br /> PUMP REPLACEMENT* .. / / State Work Done <br /> _ �. <br /> Ptll�:REPAIR: /_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II 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 ;ithe 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 OUTING:AND A F INS PE ON: A � <br /> SIGNED 7Wtef, TITLE ? <br /> (DRAW PL PLAN ON REVERSE SIDE <br /> i FOR EPARTMENT USE ONLY <br /> '. PHASE I <br /> APPLICATION ACCEPTED BY.;; DATE ' l �� <br /> ADDITIONAL COMMENTS: �. <br /> PHASE II GROUT INSPECTION el PHA E II FINAL INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY .�� DATE <br /> ` E H 1426 Rev. '1--74;; 2M­ <br />