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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> vv Telephone: (209) 466-6781 76ZS_�o <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74�'-IKs7h✓ <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 Phone . ' <br /> Address City s <br /> f <br /> Contractor's Name <br /> LicensePhone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP 'INSTALLATION `�` . 'UMP REPAIR' PUMP REPLACEMENT 77.:._� :•+, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL�}FIELD CESSPOOL/SEEP FIT OTHER <br /> �- PROPERTY LINF��PRIVATE DOMES:T C=.WELT� 7BLIC DOMESTIG WELL--� Erf - <br /> INTENDED USt M- E-OF_WELL _. w--CONSTRUCTION SPECIFICATIONS . <br /> Industrial ' Cable Tool _ Dia, of Well ExcavationfyC�� <br /> XJ Domestic/private r x Drilled Dia�of�Well'Casing�. :;. `���i2� <br /> Domestic/pub-Ji­ --Df'iven �, Gauge of Casing^ � _ _ y _ <br /> Irxigation., . Gravel Pack. „Dept-h'o'f'�Grout-Seal----. <br /> Cathodic Froaection A - �. Rotary �- <br /> � _ y , � Type of Grout <br /> u .., . <br /> Disposal �- Other':-- j Other Information <br /> Geophysical Surface Seal Installed By.,___ <br /> PUMP INSTALLATION:Contractor <br /> TYPe:, of Pump _v4le _ ; H.P. . <br /> PUMP REPLACEMENT: <br /> / / ; State Work Done <br /> PUMP .REPAIR: ./ /. YState 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 '.r`l dations df-',the -Sarr-Joia uin,=L-ocal _Health. District <br /> and the Stare-of-ftl-ifornia pertaining to or regulatingy ell 'construction.. _Within_.FIFTEEN DAYS i <br /> after completion 'of my work on anew 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 INSPECTION.- <br /> SIGNED TLE, c�y <br /> 71 Td.F T p ON RE FRSE SIDE ;. <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .. oma. DATE /5 C <br /> ADDITIONAL COMMENTS: An: <br /> PHAS IPGRdUT INSUCTIQW, PHASE IIXtFIWL INSPECTI <br /> INSPECTION BY t AAT INSPECTION BY DATE <br /> E H 1426 Rev. '1--74 3/76 2M <br />