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26) <br /> _ N JOAQUIN LOCAL HEALTH DISTRICT <br /> TOR* OFFICE USE: 1601-1E. Hazelton Ave. , Stockton, Cal-3..i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-5---,50 3 4/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/4/,-' — <br /> (Complete In Triplicate) �"1'`"� <br /> .pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> :nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION <br /> , ' <br /> % O - j a CENSUS TRACT <br /> wner s Name �j. c 1.�<' l� (rc, �.,00� Pizore - <br /> l� l �,�— <br /> .ddress mall �' �i�%,�1� City <br /> ontractor's Name � 1s'j9�/� / License # Phone <br /> YPE OF WORN. (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMEX/_ <br /> Other <br /> )ISTANCE 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 /> 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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: y <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP '.REPAIR: / / State Work Done _ <br /> ES•TR'JCTION OF WELL: Well Diameter L Approximate Depth 5e:9 <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd 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 /> IELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> .nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GRW <br /> WNG AND A FIN ION. <br /> ;IGNED -- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'HASE I <br /> ,PPLICATION ACCEPTED By — '7DATE�a ^ <br /> ,DDITIONAL COZZIENTS: <br /> PHASE II GROUT INSPECTION PHASE II*/FINAL INSPECTION <br /> _NSPECTION BY DATE INSPECTION BYZt, tiCcvC DATE -7.ZL1-76 <br /> Z <br /> E H 1426 Rev. 1-74 1-74 2M <br />