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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 ,FOh OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-.6 <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 Joa in Local He lth District. <br /> Ss <br /> JOB ADDRESS/LOCATION - CENSUS TRACT ' <br /> i <br /> Owner's Name Phone <br /> Address Age <br /> City <br /> Contractor's Name J <br /> License #11)"EPhone � - <br /> i <br /> f TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_% RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK 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 j <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 mother Information i <br /> Geophysical__ a. <br /> _ _•�� R„r Surface <br /> Seal-Installed BW <br /> - - <br /> PUMP INSTALLATION: Contractor e <br /> Type of Pump H•P• <br /> PUMP REPLACEMENT: . / J State Work Done <br /> PUMP .REPAIR: / / State Work Done ' <br /> � F <br /> DESTRUCTION 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 4. <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 C FOR A GROUT INSPECTION <br /> PRIOR TO UOUTING AN FINAL INS ECT ON. f <br /> SIGNED TITLE <br /> 1 DRAW Pf T' PLAN 'ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> -PHASE I <br /> APPLICATION ACCEPTED BY DATE -7 F- 7` <br /> ADDITIONAL COMMENTS: } + <br /> PHASE II GR T INSPECTION PHAS_ I/FI AL INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY j <br /> DATE 7 <br /> E H 1426 Rev. 1-74 := 3/76 214 <br />