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J <br /> f� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:,,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76' <br /> s <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued _6z �7� <br /> (Complete <br /> Application is hereby made to the San Joauin LocalHealthDistrict 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 Ru s and Regulations of the Oan .joaquin Local health District. <br /> JOB ADDRESS/LOCMpN r CENSUS TRACT <br /> i <br /> Owner's Names <br /> Phone �`���' <br /> Address City' <br /> OVi <br /> Contractor's Named License V40 Phone,44 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN '/? RECONDITIO /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION I / FUMP REPAIR PUMP REPLACEMENT_ 17 <br /> Other )/—/ -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 I Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal. # Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .af Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done ' <br /> PUMP'REPAI n1� oa�k'D`one' <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 -wellin 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`INSPE CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSP ION PHASE III/FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY DATLO <br /> E'H 1426 Rev. 1-74 ou Q <br />