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l d SAN JOAQUIN LOCAL HEALTH DISTRICTrfp k <br /> FOR OFFICEUSE: 1601 E. Hazelton 'Aue.. , Stockton, Calif.Telephone: (209) 4666781APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ! <br /> THIS PERMIT EXPIRES 1 YEAR-.FRONT DATE ISSUED Date Issued .JAN 3 - 1976 <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 6 0' CENSUS TRACT . <br /> Owners Name 4 <br /> Phone <br /> k Address <br /> City <br /> f . <br /> Contractor's,'Name License Phone y -7./7,/= <br /> TYPE OF WORK (Check) ! NEW WELL/ / DEEPEN /% RECONDITION / / DESTRUCTION /_7 <br /> 'PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT / <br /> Other <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 /> I A 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 <br /> f .Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor CS� i,�� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ..$D ' <br /> PUMP REPAIR: / / State Work Done <br /> I}ESTRUCTTON OF WELL: Well Diameter <br /> - 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 i <br /> information is true to the best of my. kno dge a d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A. FIN ISPE I� , <br /> SIGNE TLE <br /> DRAW PLO PLAN ON RE SE SIDE) <br /> I: FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE JI ROUT INSPECTION P S I /FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATESr <br /> i <br /> E H 1426 Rev. - l-74 <br />