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SAN JOAQUIN LOCAL HEALTH. DISTRICT _. <br /> F0E"QFf10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-6dtslcJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete,. In Triplicate) <br /> `Application is hereby made to the San Joaquin Liacal Health District for a permit to construct <br /> and/or instafi the work herein described. This application is made in compliance with San Joaquil <br /> County Ordinance No. 1862 and the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` <br /> CENSUS TRACT <br /> Owner's Name C' j { Phone <br /> r Address ___w <br /> City <br /> Contractor's Name'' c� ppp/Jyy�JJJ � LicensePhone <br /> TYPE OF WORK (Check) : NEW WELL 4X DEEPEN%/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /�PUMP REPAIR / / PUMP REPLACEMENT I-7 <br /> Other 1_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT, PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT/ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL { <br /> INT DED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �� r <br /> Domestic/private Drilled Dia. of Well Casing <br /> f D6mestic/public N Driven Gauge of Casing <br /> Irrigation ,r Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout ��,� - (7.g <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> y <br /> PUMP .REPAIR: / / State Work Done <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 e well and notify them before putting the well in use. The above <br /> information is t to the best my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ECT ,0 . <br /> SIGNED TITLE <br /> (DRAW m PLOT"PLAN ON REVERSE S ID r'I: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY v. DATE <br /> ADDITIONAL COMMENTS: jV <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> w <br /> E H 1426 Rev. 1-74 w 3/R 2M <br />