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b i,o' f�"eC�� � JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROr'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 11 ks r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedG <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 �.el.r� �j [,L � /V CENSUS TRACT D .5 <br /> Owner's Name 0 ti a r­�^� ��t . d Phone y6 2 <br /> Address 1-V I/ ?1 r 0e)d City <br /> Contractor's Name .; ��,,� <br /> License # / 3 72.f-Phone y 2C 76. <br /> ,r <br /> TYPE OF WORK (Check) : NEW WELL /_/ DEEPEN /% RECONDITION /-T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 USR. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing t <br /> Domestic/public Driven Gauge of Casing <br /> )C Irrigation Gravel Pack �' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> r.....,... . �� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i. P 1 --r-' , r� • H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / State / r <br /> Work Done � , <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 <br /> information is true to the best of my kno le ge and b lief I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO G-ROMTTNr AND FINAL ION. <br /> SIGNED <br /> I T L E <br /> I;OT LAN ON RSE SIDE) <br /> PHASE I <br /> EPARTMF,NT USE ONLY <br /> APPLICATION ACCEPTED-B -�� <br /> �l CD DATE 3 - <br /> ADDITIONAL COMMENTS <br /> PHASE II OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY <br /> DATE <br /> E H 1426 Rev. 1-74 <br />