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� 3 - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,76 - g 35z <br /> -113 4AP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 ADDRESSAhr=r'= 9 CaL I V& o f+1' CENSUS TRACT <br /> Owner's Name t 1� � �� Phone <br /> Address City <br /> Contractor's Name S License A;U Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEP /_/ RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION/xJ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other �" <br /> DISTANCE TO NEAREST: SEPTIC TANK (31 SEWER LINES __ PIT PRIVY <br /> SEWAGE DISP SAL IELD r•-� CESSPOOL/SEEPAGE PI 77 O- OTHER --- <br /> PROPERTY LIN209IVATE DOMESTIC WEL�J PUBLIC DOMESTIC WELL 1 <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 / 2— <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 fent. H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <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 my. knowle ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT <br /> SIGNED �1 <br /> PhC1 PL ON RE FRSE SIDE 1 <br /> PHASE I OR DEP4RTMENT USE ONLY <br /> APPLICATION ACCEPT DATE l •� <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHAS III/F NAL INSPECT 0 <br /> INSPECTION BY DATE f INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />