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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0TF 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f _ <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT r Permit No. <br /> 76-SS6 3� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In. Triplicate) <br /> Application is hereby made to the Son 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. 1$52 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4 _ <br /> JOB ADDRESS/LOCATION 606 CENSUS TRACT ' <br /> Owners Name \, Phone <br /> Address ! City ' d cA 7 o _ <br /> Contractor s Name <br /> � � rQ License Phone9 ,E-,FY1 <br /> ?; . <br /> TYPE OF WORK (Check): NEW WELL f4P-IDEEPEN /7 RECONDITION �T DESTRUCTION f7 <br /> }, PUMP INSTALLATION /c%' PUMP REPAIR' /� PUMP REPLACEMENT /7 <br /> Other <br /> DISTA—RCE-TO-NEAREST: SEPTIC 'SANK ��tSEWER LINES /;ZU 'SPIT PRIVY - <br /> .- - . SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> $'I s INTENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial , ,,-,Cable..Too1Y Dia. of Well Excavation <br /> .: Domestic/private Drilled Dia. ,,of Well Casing " <br /> Domestic/public` Driven Gauge of Casing 02 {� <br /> Irrigation. ­-Gravel-Pack- Depth of Grout Seal �, a _ -- <br /> I Cathodic Protection Rotary Type,of Grout_ <br /> ;. Disposal Other Other Information' <br /> Geophysical . Surface Seal Installed .By: /-7'- <br /> PUMP IN Contractor . - = \ <br /> Type of .Pump "" 'ems H.P. <br /> PUMP REPLACEMENT. - / / State Work Done - <br /> PUMP .REPAIR: k / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material-and Procedure <br /> I hereby agree to comply wi-th'-all l6is-anal 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 <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A INAL INSP CTIO . <br /> F SIGNED TITLE <br /> : (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEJARTMENT USE ONLY <br /> PHASE Ic �. T DATE ' <br /> APPLICATION ACCEPTED BY6 " <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY' DATE INSPECTION BYDATE <br /> E H 1426 'Rev. 1-74 - <br />