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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO-k OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 4161,41 <br /> THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED Date Issued X76 <br /> II (Complete In Triplicate) <br /> Application 'is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Fand/or install 'the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 a the Rules and Regulations of the San Joaquin Local Health District. <br /> E JOB ADDRESS/LOCATION / CENSUS TRACT <br /> Owner's Name !j Phone _Eks_ <br /> Address ! city <br /> Contractor's Name / vC License <br /> 0 of Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEILJ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/ /PUMP REPLACEMENT /-7 <br /> Other / / . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 PIT-PRIVY <br /> SEWAGEIDISPOSAL FIELD. CESSPOOi;/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 I Drilled Dia. of Well Casing (,u <br /> Domestic/public i _ Driven Gauge of Casing p <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection " Rotary Type of Grout <br /> Disposal Other ' Other Information <br /> Geophysical Surface Seal Installed By: 1 . <br /> PUMP INSTALLATION: Contractor,a46 <br /> Type of Pump '- H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> IIIF s : <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 t the-best of my"knowledge and belief. I WILL GM FOR A GROUT INSPECTIO <br /> PRIOR TO GROUTING AND FINAL! I SPECTION. <br /> SIGNED TITLE 0%2 <br /> DRAW:PE T PLAN ON REV9RSE SIDE <br /> FOR.,.DEPARTMENT USE ONLY <br /> PHASE I _... :� <br /> APPLICATION ACCEPTED BY DATE 9- <br /> ADD ITIONAI" COMMENTS: <br /> PHAS OUT INSPECTION �, PHAS /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y 4 <br /> r <br /> E'• H 1426 Rev. 1-74 , 3/76 2M <br />