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OFFICE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> :OFFICE US 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION.OR PUMP PERMIT Permit No. 76-o741�J <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued -11-.2.9-26(Complete In Triplicate) l77.` Sbw�� <br /> Application is hereby mad- <br /> 010 the San Joaquin Local health District for a permit to-; Construct <br /> E and/or install the work herein described. This application is made in compliance with .San Joaquin <br /> County Ordinance No. 1862 aad` the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION SC ` CENSUS j <br /> TRACT . <br /> Owner's Name �; 1 <br /> one <br /> Address. ` <br /> Cit' ' <br /> Contractor's Name <br /> ,�M oil 1661 License # Phone p,3 <br /> TYPE OF WORK (Check): NEW WELL Lf DEEPEN ,/? RECONDITION '/? DESTRUCTION /_7 <br /> PUMP INSTALLATION L-7 PUMP REPAIR -/-7/? PUMP REPLACEM <br /> Other L/ . <br />"DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> INTEN <br /> i <br /> PROPERTY LINE -- P DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> DED US8 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Domestic Dia. of Well Casing •� <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of GroutSeal rF <br /> Cathodic Protection ✓. Rotary Type of Grout ' ' J' <br /> -Disposal � Other ��� Other Information <br /> - Geophysical -- 14L e2c <br /> Surface Seal Installed 'B : i <br /> ,b. `4 <br /> PUMP INSTALLATION: Contractor j <br /> Type. .of Pump �H- . <br /> s <br /> PUMP REPLACEMENT: , / SCate Work Done <br /> PUMP !REPAIR: /? State Work Done . ; <br /> DESTRUCTION OF WELL: Well. Diameter + .' <br /> Describe Material and Procedure Approximate Depth <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 UTING AN A -NAL I PECTION. <br /> SIGNED TITLEd&6& .., <br /> 01 D PLOT LAN ON REV RSED PLOT LAN ON REV RSE SID <br /> PHiASE I FOR DE ARTMENT USE ONLY <br /> APPLICATION' ACCEPTED Y <br /> ADDITIONAL COMMENTS &41DATE - _vv <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYHAS III FI AL INSPECTION <br /> DATE INSPECTION BY DATE -asw 76 <br /> E A ).426 Rev. 1-74 <br />