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r� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFICE USE: Q 0 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> /I f10 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 -LIDO <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 fora 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 i CENSUS TRACT ' <br /> Owner's Name '`� �.�. _ Phone ?Rol <br /> �. Llel 3 5'/3 of c,;En Cit Address / City ' Yo r, caw <br /> Contractor's Name �� '"�'' _ ._ License # Phone -- � <br /> TYPE OF WORK (Check) NEW WELL/ / DEEPEN -/-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /�? PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> i <br /> I� DISTANCE TO NEAREST: SEPTIC TANK I ` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEJ'AGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' A-' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable Tool Dia. of Well Excavation R <br /> Domestic/private Drilled Dia. of Well Casing <br /> rt < 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 B : <br /> PUMP INSTALLATION: ', Contractor -9„ �: <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT c / / State Work Done <br /> PUMP�REPAIR:` ` ” vT T may/ / State�Work Done <br /> f,DES•TRUCTION OF WELL: . Well, Diameter Approximate Depth <br /> Ek Describe Material and Procedure <br /> 1 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> L <br /> FOR DEPARTMENT USE ONLY <br /> ! PHASE I t <br /> ,APPLICATION ACCEPTED BY XP DATE , //0- �4�+_ <br /> ADDITIONAL COMMENTS: € <br /> PHASE II GROUT INSPECTION PHA AL INSPECTIO <br /> kiNSPECTION BY DATE INSPECTION BY DATE _ <br /> _ � �+-• � r� � c��wr. c,.-�-,� lir-�c,,, <br /> E H 1426 Rev. `1-Ila __ 1 /75. 2M• , <br />