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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> /-IV <br /> /_5f?4 <br /> F0%,OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-- g9it/ ? <br /> 75- �9DId <br /> THIS PERMIT EXPIRES I, YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sar: 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 /> iCounty Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADOMOS LOCATION 5-401) ✓ �- Q�e , CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address City . ' <br /> l <br /> Contractor's' Name �.5; License phone 2/� <br /> 7;,v I wells <br /> TYPE OF WORK (Check): NEW'WELL DEEPEN/7 RECONDITION /? DESTRUCTION /_7 <br /> PUMW'7NST LATION PUMP REPAIR -/-7 PUMP REPLACEMENT <br /> Other <br /> k <br /> DISTANCE TO NEAREST:' SEPTIC TANiWQ SEWER LINESt PIT PRIVY <br /> SEWAGE DIS OSAL FIELD CESSPOOL/SEEPAGE PIT f-OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' W 'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS, <br /> Industrial Cable Tool Dia. of Well,Excavation <br /> DomesticJprivateDrilled i Dia`. of Well 'Casing <br /> Domestic/public Driven � Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protect_i_ on Rotary Type:of_Grou_ t�.._. -- <br /> Disposal Other,, L� Other Informmationm f <br /> Geophysical Surface Seal Installed 'By: € <br /> PUMP INSTALLATION:- Contractor ' <br /> k <br /> Type of Pump t 1 H.P. ! S <br /> PUMP REPLACEMENT: • /_7 State4Work Done <br /> PUMP ,REPAIR: / State Work 'Done <br /> A <br /> DES4TRUCTION OF WELL: Well Diameter ApproximaterDepth <br /> Describe Material and Procedure <br /> I hereby agree to comply withmall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to;or'"regulating"-well. ''canstruction. 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 they before putting the..well. in use.... .The above 7 <br /> information-is <br /> true_to jhe.m best,_of. my. knowledge 4and belief. 1,WILL—CALL-FORA GROUT-INSPECTION f <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED <br /> .. LE �BJI�d.G <br /> W PIADT P Q REVERSE SIDE) <br /> PRASE I <br /> FOR DEP TMENT USE ONLY <br /> ,��- <br /> APPLICATION ACCEPTED BY DATEZ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PKASA II1 FINAL INSPECTION <br /> INSPECTION BY & DATE e,?, INSPECTION BY DATE <br /> CAO <br /> . E_Hm 1426 Rev. 1--74 r !1/7q <br />