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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. >_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7_6-/!Z )0 <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3- <br /> (Complete <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A? v FRM&GA CIAAtIO , CENSUS TRACT <br /> Owners Name ®G <br /> � NG'- t - .._,..,._ Phone ,4�� C L402 7 <br /> Address t9 O L1 . S C�ty <br /> Contractor's Name License # 2 S 7d1thone 4141`Ik? <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/_7 RECONDITION -/_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR 17 PUMP REPLACEMENT-7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER g <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ' Domestic/private Drilled- Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otec,tion Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical '- Surface Seal,-Installed 'B <br /> r <br /> PUMP INSTALLATION: Contractor � . AN <br /> Type of Pump S ... H.P. l i� <br /> PUMP—REPLACEMENT: •r 7 State Work Done . _ <br /> I PUMP '.REPAIR: " <br /> -- / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k 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•'cona_truction. Within. FIFTEEN DAYS <br /> s after completion of my work onanew 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.. knowledge and belief._ \T WILL,..,.CALL-FORA GROUT—INSPECTION <br /> PRIOR TO GROUTING ANb7A"-�INAL INSPECTION, <br /> SIGNED TITLE c , <br /> D P PL N REVERSE SID � ' 4F" _.. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION B DATE <br /> k E H 1426 Rev. 1--74 h/75 -19 M <br />