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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFIG:E USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (204) 466-6781 <br /> =w ° APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS, PERMIT EXPIRES l YEAR FROM DATE' ISSUED Date Issued 1.I_S_76 ' <br /> f (Complete In. Triplicate) <br /> Application is hereby made to the Son 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 /> C County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S CENSUS TRACT <br /> ' <br />�- <br /> Owners Nal� �e_ - _.... Phone ' <br /> AddressCity ' <br /> Contractor s Name License # �°�3� .. Phone <br /> TYPE OF WORK (Check): NEW WELL '/7: -DEEPEN--/? RECONDITION /7 DESTRUCTION of f <br /> PUMP INSTALLATION/ / PUMP REPAIR'/7 PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL per, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - Xs <br /> Industrial Cable Tool Dia. of Well Excavation <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 ProtecItion Rotary Type of Grout <br /> Disposal Other Other Information ( <br /> i <br /> Geophysical <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> ` ... Type of 'Pump H.P. <br /> k PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / :State Work Done <br /> f DE&TRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k 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 anew well, I will furnish the San Joaquin Local Health District <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 ROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE (` <br /> DRAW PLOT PLAN ON REVERSE SID V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE [� <br /> ADDITIONAL COMMENTS; <br /> PHASE 11 GROUT IN ECTION . PHASE Ia FUU INSPECTION <br /> k INSPECTION] BY DATE INSPECTION BY DATE -ZZ-7C <br /> E N 142'6 Rev. '1-74 f 4/75 2M <br />