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C - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton" Ave. ,. Stockton, Calif. <br /> Telephone: (209) ,466-67$1 <br /> APPLICATION FOR WELLCONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76-///A P:v <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/b@0A46k_ N7 n �.® p � CENSUS TRACT <br /> Owner's Name �f Qgl _--- - Phone <br /> Address City <br /> Contractor's Name 0 Y, 6'L (5 License Ahone � <br /> TYPE OF WORK (Check) : NEW WELL '_X DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /�' PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A= PIT PRIVY <br /> SEWAGE DISPOSAL IELD (F-0—f- CESSPOOL/SEEPAGE PIT -T— OTHER— <br /> PROPERTY LIN RIVATE DOMESTIC WELI� J�PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL °­7 . ,-GONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ^'T4 Driven Gauge -of Casing <br /> Irrigation Gravel Pack Depth'of-Grout Seal <br /> Cathodic Protection Rotary Type of Grout t <br /> Disposal Other Other Information ' <br /> Geophysical -AAA � � Surf ace W Seal_ In`s taped By: <br /> PUMP INSTALLA'T'ION: Contractor <br /> i <br /> Type of .Pumpc H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / -..,State Work Dorie <br /> ,DES-TRUCTION 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 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 CALL F04 A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI _ Y� - <br /> SIGNED =TITLE � clz <br /> W L LAN 'ON RE FRSE SIDE) <br /> FOR- EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 'ADDITIONAL COMMENTS: <br /> P E II QROUT INSPECTION PHAV III/FINAL INSPECTION/ <br /> INSPECTION BY DATE /I INSPECTION BY DATE <br /> 3/760 <br /> E H 1426 Rev. 1-74 �� <br />