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f/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E: <br /> FOOFFICE USE: v 1601 E. Hazelton Ave. Stockton, . . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-a�sl� <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 Sen Joaquinl7 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local HealthDistrict. " <br /> JOB ADDRESS/LOCATION <br />. CENSUS TRACT � z ' <br /> Owner's Name ` <br /> . Phone '. <br /> Address <br /> - City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION f7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/77—PUMP REPLACEMENT /7 <br /> Other '07 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Protection Rotary Type of Grout ' !p, <br /> Disposal Other Other Information : . <br />'t GeophysicalSurface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. . p <br /> PUMP REPLACEMENT / / 'State Work Done <br /> PUMP '.REPAIR: State Work Done 3,w <br /> DESTRUCTION OF WELL: Well.,Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F 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 "construetion. 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 GROUTING 'AND A FINAL INSPECTION. / <br /> SIGNED TITLE Lrt <br /> DRAW PLOT PLAN ON REVERSE SIDE _„--- <br /> FOR DEPARTMENT USE ONLY <br /> II PHASE I <br /> APPLICATION ACCEPTED BY t1i DATE JAG <br />'E ADDITIONAL COMMENTS: <br /> PHASE II GROUT ,INS CTION PHAS II FINAL INSPECTION <br /> INSPECTION BY DATE y INSPECTION BY DATE <br /> E H 1426 . Rev. 1-74 �f h/75 2M ' <br />