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i° SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No._ 76,= <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 aid the Rules and Regulations of San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION" l,57- CENSUS TRACT <br /> Owner's Name 4�?7 Phone <br /> Address <br /> Contractor's Name '' /�/ License Phone <br /> i <br /> TYPE OF WORK (Checks) . ' NEW'.WELL �/_: �/ _"DEEPEN I I�TRECONDITION / / 1 DESTRUCTION /� <br /> " PUIIII _ <br /> AL <br /> TLATION / ] PUMP REPAIR I I i PUMP REPI;ACEMENT - <br /> Other 1-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> !I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> I PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ,N TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well EXcavation <br /> 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 Typ6lof Grout <br /> Disposal Other �Othdr-Information ' <br /> Geophysical ;' Surface.-Seal Installed By: <br /> PUMP INSTALLATION: Contracto �, `�C # �' <br /> Type of Pump H.P. . /. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ij <br /> PUMP .REPAIR: I� / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 3 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.1 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 knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO WUTING a A FINAL INSPECTION. "s <br /> 5 <br /> SIGNEDTITLE <br /> DRAW PT TPLAN ON RE FRSE SIRE) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I �I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: } <br /> PHASE 'I GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE 7 Z2-7� <br /> 3/76 2M <br /> E H 1426 Rev.;J-74 -` <br />