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l� SAN JOAQUIN LOCA. HEALTH DISTRICT <br /> FOi ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zti�c� <br /> 76 /es6le' <br /> THIS PERMIT EXPIRES l YEAR FRONT .DATE <ISSUED Date Issued/ <br /> �� {Complete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local .Ilealth 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/ Gr 17 n CENSUS TRACT <br /> Owner's-"Ni6e V i Phone ' <br /> Address I _ City _ T_ <br /> Contractor's Name y'vj/ M s License7"� Phone /� Z(o <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/-7 RECONDITION /7. DESTRUCTION /j <br /> PUMP INST LATION ' / PUMP REPAIR/� PUMP REPLACEMENT f7 <br /> Other %/ _W <br /> DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD W-, CESSPOOL/SEEPAGE PIT/ - OTHER t-p <br /> PROPERTY LINEVORIVATE DOMESTIC WELL 7-0 PUBLIC DOMESTIC WELL (, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i! Cable Tool Dia, of Well' Excavation v <br /> Domestic/private Drilled Dia. of Well Casing,_ <br /> Domestic/public "` DrivenGauge of Casing 2... \ <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 Af 0 '1 L <br /> ,g <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 /> 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 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 INSPECTIO <br />' SIGNED 2V4- <br /> ITLE <br /> DRAW PLOT P ON REVERSE SIDE <br /> F R DEPAJXMENT USE ONLY <br /> PHASE I <br /> PLICATION ACCEPTED f co ATE /0-7-7 <br /> AP - 76 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIff <br /> INSPECTION BY LIPDATE ,e/ I� 77W INS ECTION BY p. . DATE of AQ, <br /> E..H-1426 Rev. 1-74 <br /> _ L/75 2M- <br />