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h� ! � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> > FOAr OFFICE 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. 0 <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 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 CENSUS TRACT <br /> Owner's Name n<1 u Picone <br /> Address - .' / t-) 02-. City <br /> Contractor's Name ' J; License # ' one 6 -1 -76 74 <br /> .TYPE OF WORK (Check): NEW WELL/_7 DEEPEN / r <br /> RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION / 7 PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> d j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )C domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> A Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed- By: <br /> 1 <br /> ,PUMP INSTALLATION: Contractor <br /> Type of Pump I H.P. / <br /> PUMP ff State Work Done r" ,�,,.. <br /> IV 10 Id <br /> PUMP !REPAIR: L7 State Work Done <br /> ES;TRUCTION 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 puttingthe well in use. The above <br /> information is true to the best of. my led a0d- a ief, I WILL CALL FOR A GROUT INSPECTION <br />. PRIOR TO 912U INC AND A FINAL INSPECT ( <br /> SIGNED fr!/ c.. LE <br /> D P PLAN ON REV SE SIDE) ' <br /> R DEP T USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY Cif DATE IL I2` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III INAL INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4 <br /> 44 B H 1426 Rev.. 1-74 1-74 2M <br />