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r !h <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 6,70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76 7p710 <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/6A66N ;F l f CENSUS TRAGI <br /> Ownerva Name I� � Phone <br /> Address2ErAg,,e� City.. <br /> Contractor's Name ,G " 4 License �� hone r <br /> TYPE OF WORK (Check): ANEW WELLDEEP /7 RECONDITION /_7 DESTRUCTION <br /> PULP INST L�LATION � / MP PUMP REPAIR PUREPLACEMENT17 <br /> ;Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SWAGE DISPOSL TEED `�` /SFPAGE PIT �-OTHER— <br /> E PROPERTY LIN RIVATE DOMESTIC'-WEL PUBLIC DOMESTIC WELL <br /> INTENDED USE �! TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrials Cable Tool 7 -Dia: of Well Excavation <br /> F Domestic/private ;� Drilled Dia. of Well Casing <br /> ff Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout- Seal <br /> Cathodic Protection r � Rotary Type of Grout <br />' Disposal Other Other Information <br /> Geophysical. Surface Seal. Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pu _ H.P. ._ <br /> s PUMP REPLACEMENT: y/ / State Work Done µ <br /> PUMP REPAIR: State Work Done <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,11,the well and notify them before putting.the .well. in use.... ,The above <br /> information is true to--the-best.af My knowledge and belief. I WILL CALL FOR 'A 'GROUT -INSPECTION <br /> PRIOR TO GROUTING AND A1.1FINAL INSPECT e <br /> SIGNED a _ LE <br />' 1f }RAW PLOT P ON REVERSE SIDE <br /> FO DEP TMENT USE ONLY <br /> PHASE I � <br /> APPLICATION' ACCEPTED BY . DATE 0 � �C <br /> ADDITIONAL COMMENTS: <br /> It - 7z <br /> PHASE I ROUT INSPECTION PHASE IIF AL INSPE I N <br /> INSPECTION BY DATE 3! ? INSPECTION .BY DATE <br /> E H 1426,,,, Rev. 74 r` h/75 2M <br />