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OAQi:I LOCAL HEALTH DISTRI.'i' <br /> L„OH,OFFICF USE: 1601 Hazeltml Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y_ 36J4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-/6-74, <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> a!Nd/or install the work herein described. This application is made in compliance with San Joaqui <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1.3 ADDRESS/LOCATION J26QQ - ENSUS TRACT <br /> J ier's Name Phone A SS _ 7 i7 <br /> dress �J n (7 �20 f4_2__,C <br /> ) ,CCity <br /> Litractor's Name �1 o-License U , 'l Phone <br /> �S7,n L!/ Arlt T4 it Fi X7) 7 si b <br /> 'E OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> V PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> t3TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> x SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL 6 <br /> ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic <br /> /private Drilled Dia. of Well Casin <br /> _ Domestic/public Driven Gauge of Casingg <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection --j-_7 Rotary Type of Grout ,Qpy� mA. r <br /> _Disposal Other Other Information <br /> Geophysical —�2 b —12,! <br /> — Surface Seal Installed By.. <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: / / State Work Done - 3 Q - 7� <br /> ' P 'REPAIR: f% State Work Done <br /> � Q TRUCTION OF WELL: Well Diameter Approximate Depth <br /> �. Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Lthe State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> A ormation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR TOOUTING AND INAL IN CT <br /> IGNED �, G t {y �/ , TITLE <br /> DRAW LOT P ON REVERSE SIDE) <br /> OR DEPAR' T USE ONLY <br /> 6SE I ( %' <br /> PLICATION ACCEPTED `BY i f <br /> LZTIONAL COMMENTS: <br /> ATE <br /> PHASE II GROUT INSPECTION PZ / AL INSPECTION 7 <br /> NSPECTION BY DATE INSPECT DATE <br /> I <br /> E H 1426 Rev. 1-7A <br />