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0� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTr <br /> LFy�;XfFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-5'310 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued ,7;j <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. 186' and the RulesandRegulations of the San Joaquin Local Health District. ' <br /> JOB ADDRES S/LOCATION 1' r4P o_j 4( re &jA CENSUS TRACT <br /> Owner's Name ��: /�` Phone <br /> I�. <br /> AddressIr' r' u City ' <br /> Contractor's Namel// ,_ License # A.5 phone <br /> h <br /> TYPE OF WORK (Check) : NEW WELL '/_ .DEEPEN '/-M RECONDITION /7 DESTRUCTION /f <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <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 Q\ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> K Domestic/private Drilled Dia. of Well,- Casing <br /> Domestic/public Driven Gauge of)Casing � <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection- Rotary Type of' Grout <br /> l <br /> Disposal Other Other Information " <br /> Geophysical. � Surface. Seal Installed By: f` <br /> " f <br /> PUMP INSTALLATIONS Contractor "t/V <br /> Type .of Pump f H.P. Nom' r <br /> PUMP REPLACEMENT: hj State Work Done ' f <br /> PUMP '.REPAIR: / State Work Donee <br /> I <br /> DESTRUCTION OF WELL: Weh11 Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> I hereby agree to complyi`:wi,th 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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL. DRILLERS REPORT of the well and notify1them before putting the..well. in use.... The above <br /> information is true to the•best 'o _tgy_.knowlPd ge d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO, GROUT NG AND A 1'IN „S,P N <br /> SIGNED . r # TLE` (D PLOT' ON SE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I F - <br /> APPLICATION' ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III 4EINAL INSPECTION <br /> f <br /> INSPECTION BY •.II DATE - INSPECTION BY ✓ DATE ✓-1 i <br /> E H 1426 Rev. 1-74 r <br />