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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 PERMIT Permit No. 76- F/4� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,a V-76 <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 CENSUS TRACT <br /> Owner's Name Phone <br /> Address 35 City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /7 PUMP REPAIR -1-7—PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE �- PRIVATE DOMESTIC WELT,' 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 /> PUMP 'REPAIR: -7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth �Q <br /> Describe Materialand Proc dure <br /> ' <br /> I hereby agree to comply with all aws and regulations of the San Joaquin%Loca'l 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 TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DAT a1- a.�-{- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA NSPECTION <br /> INSPECTION BY DATE INSPECTIONBY D <br /> ti <br /> E H 1426 Rev. 1-74 t,/V� <br />