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co � <br /> SAN 1OAQUIN LOCAL HEALTH DISTRICT <br /> FO�OFF���'SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> : <br /> Tele <br /> honep (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued -moo-76 f <br /> �r (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 incompliance with San Joaquin, <br /> County Ordinance No. 1862 and ,the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION n G,� C y GQ CENSUS TRACT <br /> Owner's Name _ Phoxae <br /> Address 0,66 r It �a City .—fop, 4 <br /> i <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL -17 DEEPEN 17 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/x/ PUMP REPLACEMENT % 7 <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. Cable Tool Dia. of Well Excavation �I <br /> �sDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation , Gravel Pack Depth of Grout- Seal:-- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other "Other Information <br /> Geophysical. Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump tc .✓ G H.P. ._ <br /> r <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP ,REPAIR: State Work Done k-oL F <br /> f <br /> DE&TRUCTION_OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t . <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 M <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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A PINAL INSPECTION. <br /> SIGNED �� ,,, r ITLE P,-*x - <br /> (DRAW , PLAN ON .RE RSE SIDE) 7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION PHAM-AW/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY 4. DATE fd ! <br /> E H 1426 Rev. 1-74 r h/75 2M <br />