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� b <br /> SAN JOAQUIN LOCAL,_HEALTH DISTRICT <br /> F0K OFFICE USE: 1601' E. Hazelton`Ave , Stockton, Calif. <br /> J a Telephone:, (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 ;1 3kJ � <br /> 76 - <br /> THIS PERMIT EXPIRES 1 YEAR FROM YDATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Elealth District -for a permit to construct , ' <br /> and/or install, the work herein described. This applicatic' n 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 /> .TOB ADDRESS/LOCATION 4` ® CENSUS TRACT j <br /> Owner's Name Phone <br /> Address L o2 ® 4 & ACity S tfc 7?,w! <br /> Contractor's Name !� cerise <br /> /Phone <br /> a <br /> TYPE OF WORK�(Check)-. NEW WELL_�A_j---D_EEPEN '/-7 RECONDITION L7- DESTRUCTION /7 A <br /> PUMP INSTALLATION /�-PUMI? REPAIR-/—/ .PUMP REPLACEMENT <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '-..;— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - L.�able Tool Dia. of Well Excavation <br /> ,�Uomestic/ private ' Drilled Dia. of Well Casin \ <br /> Domestic/public Driven Gauge of.Casing <br /> Irrigation -Grsve1.P"4ck Depth of Grout Seal (J <br /> r Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information # <br /> Geophysical Surface Seal Installed B <br /> �. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT --4" <br /> a <br /> State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate+ Depth <br /> Describe Material and Procedure I <br /> fI 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"const-r-uetion. 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 FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU IN AND A FIX& INSPECTION. i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I 0 EPARTMENT •USE ONLY <br /> APPLICATION ACCEPTED BY TE <br /> ADDITIONAL COMMENTS: <br /> P PHAS NSPECTION <br /> INSPECTION BY 1 DA E INSPECTION BY DATE <br /> - ._E,H 1426 7. 1-74 r' 1./7C ]u ! <br />