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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 <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 herein described. This application is made in compliance with San 3ict. # <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distrrict, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Phone <br /> Owner's Name x <br /> t <br /> Address City <br /> License }}141 <br /> 11 <br /> Contractor's Name # 1423Phone <br /> 4bb- b� <br /> t <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN_/ / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR-0 PUMP REPLACEMENT 17 <br /> Other / f <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing `4 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection " i Rotary , ' Type of Grout <br /> Disposal ► Other Other Information V <br /> ! Surface Seal Installed By: _ <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type. of Pump <br /> PUMP REPLACEMENT: / <br /> State Work Done <br /> PUMP:REPAIR•:_° J J ,State Work _Done:=_ <br /> DESTRUCTION OF WELL: Well Diameter <br /> approximateDe� <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 worklon 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 UOUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE - <br /> . , ,:,�, is <br /> �� DRAW <br /> PUT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENTUSE ONLY <br /> PHASE I '" • ' : <br /> APPLICATION ACCEPTED BY DATE ,- Q 7 <br /> ADDITIONAL COMMENTS,: . J PHASE III/FINAL INSPECTION <br /> PRASE ;II GROUT INSPECTION DATE <br /> INSPECTION BY _ °s' DATE INSPECTION BY �- /�_7G — <br /> i 3/76 . 2M <br /> 4 E H 1426 Rev. 1-74 __ <br />