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/act' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: -/v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1/-Ig-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 c&9 CENSUS TRACT <br /> Owner's Name __5?l,wrl Phone l�L_ <br /> Address i' City <br /> Contractor's Name / License i�Z� Vhone� <br /> TYPE OF WORK (Check): NEW WELL/ZT DEEPEN �/� RECONDITION /- DESTRUCTION /_7PUMP INSTAL"I ATION PUMP- REPAIR"/_7--PUMP REPLACEMENT /-J <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER q <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 3-0-11 <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 - A.P. <br /> PUMP REPLACEMENT j/7 State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> nES•TRUCTION 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 af. my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR U ING A F AL NSPECTION. <br /> SIGNED 1 TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P SE. IId OUT.INSPECTI - - - PHAS AL INSPECTION <br /> INSPECTION BY 2j DATE INSPECTION BY DATE <br /> U op 41111'S17,2 <br /> E H 1426 Rev. 1- 74 <br /> 4175 <br />