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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermitNo. 76 y 97t�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-7L <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q - CENSUS TRACT <br /> Owner's Name (,(h Phone <br /> Address _ �QIs- <br /> Contractor's <br /> LQ - City <br /> se Phone 52:2 IeSl <br /> � <br /> Contractor s Name Licen � o �O_�/ <br /> LL <br /> L <br /> TYPE OF WORK (Check) : NEW WELL /,Pp' DEEPEN / / RECONDITION_/ / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7� SEWER LINES 7D PIT PRIVY p , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 60 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _2_92EVt DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation //`.. Q <br /> �- Domestic/private . ,. Drilled Dia, of Well Casing b" zda � { <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1� <br /> Cathodic Protection �� Rotary Tyre of Grout <br /> Disposal Other Other Information <1aA--- <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> =2 / <br /> Describ Material and Proce ure <br /> &i4 iA�ellrc�J <br /> I here agree to comp194'Wt 'ti-a31`etas and gi l t- =f a .au-�JoaquinwL6ta1 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 GRO TING ANDA IN INSPE ION <br /> SIGNED444 , TITLE <br /> D16 <br /> WRE ON FRSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHA TI N INSPECTION <br /> INSPECTION BY DATE INSPECTION BY a DATE <br /> i <br /> = 3/76 2M <br /> i' <br /> E H 1426 Rev. 1-74 <br />