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FOB OFFICE USE; 160SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED <br /> Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit Nn.:76_ S�cd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued)4/ <br /> Applicata iyereby made to the Sun(ComJoaquineLocal HealthIn TriitDistrict 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/LOCATION ,4 G H)0d CENSUS TRACT <br /> Owner's Name Phone ' 3 6 y k a <br /> - <br /> AddressLZ <br /> u <br /> .Z E ACAAfO /2 City G. <br /> Contractor's Name 7? Jho$" 'LG /LG/y License #-29g SQ Phone 7�r 3�g2S- <br /> TYPE OF-WORK (Check): NEW WELL IX DEEPEN '/? RECONDITION DESTRUCTION /7 <br /> PUMP,INSTALLATION PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other <br /> l <br /> DISTANCE TO NEAREST: SEPTIC TANK /:2ri . 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 _ x Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing _ A, <br /> Domestic/public .��';Driven Gauge..of,_Casing <br /> Irrigation Gravel Pack Depth of Grout Seal p ' <br /> Cathodic Protection Rotary <br /> Disposal Type ofGrout <br /> :Other Other Information <br /> Geophysical Surface Seal InstalledBv: a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT¢ / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION 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 the well and notify them before putting.. the.-Well. in.use.... .The tabove <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 FINAL INSPECTION. <br /> SIGNED TITLE _ ' <br /> :KDRAW PCOT PLAN ON REVERSE SID � <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> . <br /> 12 <br /> APPLICATION ACCEPTED BY DATE- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PEASE 1117F INSPECTXON <br /> INSPECTION BY DATE INSPECTION BY ,(':�� � ._ DATE ld <br /> E H 1426 Rev. 1-74 r 4/75 2M <br />