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�J ,� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOO OFFICE USE: /7 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ATelephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76_ g,3Z4�j <br /> ` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�3-�� <br /> Application is hereby made to the San(oaq in Local Health District <br /> r a permit <br /> and/or install the work herein described. This application is made incompliancetwithnSan Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> cENsus TRACT <br /> Owner's Name c�' � - , <br /> Phone 9,6- 1- ? 54 <br /> Address0-4 — q Cit p t� <br /> Contractor's NaIDe n rc ®� <br /> License # ' `f Phane <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/7 RECONDITION /7 DESTRUCTION /7PUMP INSTAL TION L-7 PUMP REPAIR <br /> Other /-7 1-7—Pump REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC NK TA <br /> SEWER LINES //D PIT PRIVY <br /> SEWAGE DISPOS FIELD _ CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIOTHER <br /> C WELL PUBLIC DOMES IC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> _ Cable Tool Dia. of Well Excavation <br /> Domestic/private ' <br /> Domestic/public Drilled Dia. of Well Casing 7� <br /> /public Driven Gauge of Casing �„� • <br /> Irrigation Gravel Pack <br /> Cathodic Protection Depth of Grout SealATO <br /> .Disposal � Rotary Type of Grout �.. <br /> p o Other Other Information <br /> Geophysical ---- <br /> Surface Seal InstalledBv: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: f/7/ State Work Done <br /> PUMP :REPAIR: L? State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulationsof 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 <br /> the- well in use.. The above <br /> information is true to the best of my owledge and belief.PutI WILL CALL FOR A GROUT IN PECTION <br /> PRIOR TO G I AND FINAL INSPECTI <br /> SIGNEDF <br /> F_ TITLE ' -, <br /> Al <br /> D P T PLAN ON REVERSE SIDE } <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCE _B <br /> ADDITIONAL COMMENTS: TE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION B • DATE -7 INSPE N III INSPECTION <br /> DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />