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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �- �-7 � <br /> Telephone: (209) 466-6781 ' <br /> APP ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 6StrJ <br /> 77 s pp <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 3-'/ O S <br /> 4 ' CENSUS`TRACT <br /> Owner's Name ��� �/ �' /a /� ; - Phone ---- �' <br /> Address 9' 011' - �C City Cj <br /> ,d�� �{ e <br /> Contractors Name /- r License• S� Phon <br /> TYPE OF WORK (Check) : NEW WELL /Z./rHEEPEN / / t RECONDITION DESTRUCTION <br /> PUMP;INSTALLATION 's/t-4--PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK dD SEWERCLINES . PIT PRIVY <br /> , ' . ,SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT OTHER <br /> --PROPERTY LINE - PRIVATE' DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 111 INTENDED USE TYPE OF WELL -CONSTRUCTION SPECIFICATIONS <br /> h Industrial ale-Tool--- --Dia. of Well' Excavation <br /> domestic/private Drilled Dia, of Well Casing <br /> Domestic/public — <br /> Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> k Cathodic Protection Rotary Type of Grout 19 ,S'. -'CIA- <br /> t Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B : <br /> PUMP ,INSTALLATION: Contractor <br /> Type of Pump H.P. Qz <br /> �t PUMP ,REPLACEMENT / ./ State Work Done <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 to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU N D A FINAL INSPE <br /> SIGNED TITLE <br /> I(DRAW4= PLAN ON REVERSE SID I: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J <br /> APPLICATION ACCEPTED BY l DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIGROUT INSPECTION FINAL INSPECTION��7 <br /> INSPECTION BY DATE -- �� INSPECTION BY DATE <br /> • � �." <br /> 3/76 2M <br /> E H 1426 Rev. '1--74 j <br />