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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT;'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. jr► <br /> THIS .PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED Date Issued /.2-x-5-76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> sand/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Reg latione a e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> - CENSUS BRACT <br /> Owner's Name Phone <br /> Address / City! <br /> 'Contractor's Name License/ F ;� hone J24 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/? RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /A PUMP REPLACEMENT <br /> Other /_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 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 By, <br />( PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PtJMP'�.REPAIR: - f / "State Work Doneau-v" )161� . <br /> PESjRUCTION 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 /> f 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 TITLE <br /> a (DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I1 <br /> f'APPLICATION' ACCEPTED BY DATE <br /> .ADDITIONAL COMMENTS - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE ti <br /> F <br />