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ed L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EF, ;OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,76_�w <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 heroin described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations <br /> �-o~fftthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ^� r� d 1 .1'�aw CENSUS TRACT <br /> Owner's Name ►., &-r-% Phone <br /> Address City ' B: <br /> Contractor's Name License # 011 <br /> .. Phone <br /> TYPE OF WORK (Check) : NEW WELL.'/? DEEPEN /7 RECONDITION /? DESTRUCTION 1f <br /> PUMP INSTALLATION / PUMP REPAIR '/ PUMP REPLACEMENT <br /> Other Ll -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE B5aSTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C,U <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection RotaryType of Grout .41IN <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: a <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump 41 H.P. , <br /> PUMP REPLACEMENT: . / / State Work Done i <br /> PUMP ,REPAIR: State Work Done <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 <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 ury Howled e-an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT ON. <br /> SIGNED TTLE ' <br /> UL (D W T AN ON RE SE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6 ;x.�3 <br /> E H 1426 Rev. 1-74 h/75 2M <br />