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AN C G [/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.C'FF C USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nb. 76- 9p <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -28=26 <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 / 031 CENSUS TRACT <br /> Owner's Name t4r ��x J ��J" Phone <br /> Address 6 , f <br /> .�, City <br /> Contractor's Name s ` ,.License # Phone 7 4.' <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN / 7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION _7 PUMP REPAIR/-7—PUMP REPLACEMENT f-J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROFERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q <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 B <br /> PUMP INSTALLATION: Contract r ��" ,� <br /> Type of Pump H.P. y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP <br /> R: 57 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 1Wbwledge end belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL f SP f <br /> SIGNED " <br /> DRAW PLOT PLAN ON UkSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASE II FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />