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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466--6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR ,PUMP PER Permit No. 76'_ a)alO <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> .TOB ADDRESS/LOCATION la U CENSUS TRACT <br /> Owners Name I'd Phone <br /> Address S City .._ - <br /> Contractor's Name ,��j License # �J.P373 Phone 9 S <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN ,/-7 RECONDITION f7 DESTRUCTION /7 <br /> "" . PUMP INSTALLATION I J PUMP REPAIR-/� PUMP REPLACEMENT /�{? <br /> Other /7 . . . . . . _7 <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 1 Cable Tool Dia. of Well Excavation Cl�' <br /> Domestic/private i Drilled Dia. of Well Casing ,{ <br /> Domestic/public '1, Driven Gauge of Casing ' <br /> Irrigation i+ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �3 Rotary Type of Grout <br /> Disposal Other Other Information - -- -.r <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. , <br /> PM REPLACEMENT:_.;_ e'State,Work bone.' _ <br /> PUMP _REPAIR: State Work Done <br /> UES;TRUCTION OF WELL: Well, Diameter Approximate Depth x <br /> 'Describe Material and Procedure <br /> r <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 INSPECTION. <br /> SIGNED r j �h. TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 5� <br /> ADDITIONAL COMMENTS:: <br /> PHASE II GROUT IN PECTION PHASE III FINAL INSPECTUM <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> T 7 <br /> JE -H 1426 Rev. 1-74 11175 - 2m <br />