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f' <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR OFFICE USE: 601 'E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT �ermit No. 7y-SS-�C[J <br /> 76-76 ?J0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g-� 6 <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.t_erRulesSand Re rations of the San Joaquin Local Health District. <br /> [f d' CENSUS TRACT <br /> JOB ADDRESS/LOCATION C�L � ���'� � / C� <br /> } Owner`s Name C� Phone �a r ^ <br /> Address City <br /> f License 4t%,_ 37� Phone3g <br /> Contractor s Name <br /> { TYPE OF WORK (Check) : <br /> INEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION .. PUMP REPAIR / / PUMP REPLACEMENT /r7 <br /> Other <br /> DISTANCE TO NEAREST: i SEPTIC TANK 910" SEWER LINES / D491 PIT PRIVY <br /> SEWAGE DISFOSAL FIELD g bi CESSPOOL/SEEPAGE PIT OTHER <br /> E PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL U <br /> r -INTENDED�-USE --"�""���E"ffF6"WE1L --CONSTR�TCTION-S EGIFICATIONS \ <br /> Industrial Cable Tool- Dia. of Well Excavation `�� `' <br /> Domestic/private !, . <br /> �•Drilled---'--�?`-4 • Dia. of Well Casing <br /> Domestic/public _ , �; D,riven � jGauge of 'Casing <br /> Irrigation _ ; `',d ave1 Pack jDepth of Grout Seal <br /> �_ Cathodic Protection _lli.tary� TYpe yof Grout s <br /> i Disposal 1 �^ O herather'��Information r <br /> Geophysical _-Surface- Seal Installed By <br /> PUMP INSTALLATION: € Contractor <br /> Type 0f4Pump H.P. <br /> I 55r <br /> PUMP REPLACEMENT: /_/ 'State,,Work Done <br /> PUMP .REPAIR: / / State Work <br /> `.1 Y A r ximate Depth <br /> DESTRUCTION OF WELL: [ Well Diameter pp ' p <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 .-Loc <br /> Health District a <br /> WELL DRILLERS REPORTIof the well and notify them before putting the well; inIuse. The above <br /> information is true i o the best of my. knowledge and belief. I WILL CALLFOR A GROUT INSPECTION <br /> i PRIOR TO GRO G AL INSPECTION. I <br /> SIGNEDTITLE <br /> PI4 T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ! PHASE I - " '•-�.r'� f `. <br /> APPLICATION ACCEPTED BY: -- ' .N r DATE �g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY '�,._ DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />