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1 / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OE,"05FFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- -1 4l <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and •Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name P Phone <br /> Address �_ City r <br /> Contractor's Name License �� Phone <br /> f N <br /> TYPE OF WORK (Check),. NEW WELL ' DEEPEN / 7 RECONDITION / Jr DESTRUCTION f_7 <br /> PUMP INSTALLATION / PUMP REPAIR/ PUMP REPLACEMENT /7 <br /> :.Other /% <br /> D TANCE O NEARE T: SEPTIC TANK S[j SEWER LINES PIT PRIVY <br /> ' _may l 7 SEWAGE DISPOSAL FIELD C5Z CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE = M .� TYPE OF WELL CONSTRUCTION SPECIFICATIONS f� v <br /> Industrial . - a Cable Tool Dia. of Well Excavation /p <br /> Domestic/private- - Drilled Dia. of Well Casing r 61" <br /> Domestic/public ,Driven Gauge of Casing ! <br /> Irrigation Gravel-. Pack Depth of Grout Seal �:f?b JF <br /> Cathodic Protection ; 7<. Rotary Type of Grout <br /> Disposal Other Other Information <br /> i Geophysical Surface Seal Installed 'B : <br /> F PUMP INSTALLATION: . "Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done {' <br /> PUMP REPAIR-r— "" `/_/ State Work'Dona�"" <br /> • DESTRUCTION OFWELL: .: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.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR NG ANDA NAL INSPECTION. <br /> SIGNED �.n _ _ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY 7� <br /> t PHASE I <br /> APPLICATION ACCEPTED BY DATE 48L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> i INSPECTION BY DATE � ` z-Z�� INSPECTION BY °: DATE io J.71-14 <br /> E H 1426 Rev.-d-74 75 - 2M-__ - <br />