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V SAN JOAQVIWWCAL HEALTH DISTRICT <br /> FOS!'OFFICE USE: 1601 E. Hazeltdn Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-jkld <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued /-la�7 <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 Ru es an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI `� � `A <br /> CENSUS TRACT <br /> Owner's Name fA&APhone <br /> Address <br /> f' City <br /> Contractor s .Name <br /> - -`�., �. en <br /> se � �� Phone <br /> - - ^• - r iwr'"- wr�.�_:-rte=�.:r.: +'-ti.. .�{.'w` � ,.,_ ._, _ - •w <br /> `"s v <br /> TYPE OF WORK (Check): NEW' WELL DEEPEN -/--7=RECONDITION*',/�—DESTRUCTION /7 <br /> PUMP-INSTALLATION /"/, -PUMP REPAIR 17 PUMP REPLACEMENT J f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK'f .SEWER.'LINES yS�iy--PIT -PRIVY + <br /> SEWAGE DISPOSAL FIELD b r. CESSPOOL/SEEPAGE FIT OTHER 1 <br /> PROPERTY-LINE .- PRIVATE DOMESTIC WELL`-''S PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable'-Tool .Dia. of Well Excavation <br /> _ Domestic/private r Drilled Dia, fo-f"'We-TI Casing i <br /> lm <br /> Domestic/public Driven <br /> � ,. t Gauge of Casing . <br /> r <br /> Irrigation `"`` 1 <br /> g Gravel Pack �r Depth of Grout Seal <br /> Cathodic Protection Rotary Type.. of `Grout � <br /> Disposal ' '` cl Other ..Other In€ormation <br /> Geophysical <br /> Surface Seal Installed B <br /> { <br /> PUMP.-INSTALLATION: Contractor Y, ` <br /> aType mp H.P. <br /> PUMP REPLACEMENT: / . / State Work Done o <br /> PUMP':REPAIR: �' / -State Work Done - <br /> ES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth 6-6 <br /> .b Describe Material and Procedure <br /> � j A - <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.. like above <br /> information is true to, the-best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLEC <br /> _ 12DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �, DATE <br /> ADDITIONAL COMMENTS: ° i <br /> PHASE I GROUT INSPECTION PHAS I N INSPECTIO <br /> INSPECTION BY DATE - '�S INSPECTION BY DATE <br /> ~E H 1426 Rev. 1-74 — j <br />