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S vv f'R rid' 7a <br /> ► SAN JOAQUIN LOCAL HEALTH DISTRICT ,PSG ' meol s �FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 0"##- <br /> Telephone: <br /> -Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ^(® <br /> JAN 16 1976 <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 andel the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �`J 7 7 v � Fyl1/ ,� CENSUS TRACT <br /> Owner's Name "j f v/Z /g'ZJ5 V g D 0 Phone 77 <br /> Address -SA-A4 e City �0 <br /> s Contractor's Name ( ri 619 SMA ka kLicense # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / p <br /> . CiJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY kA <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <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 /> iomestic/public Driven Gauge of Casing <br /> rrigation 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 H.P. 1p <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 above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL NS ECTION. <br /> SIGNED TITLE 0_e,jr <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION,, P I /FIN INSPECTION �j <br /> INSPECTION BY DATE INSPECTION BY� DATE .S=/- '70 <br /> E H 1426 Rev. - I-74 � C?� L � 7 2I+P <br />