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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF , FF.IC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 1--' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76 --S 73 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) y <br /> Application is hereby made to the Sart 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 -_ _ I- _� p"'g uupD d 6 Ile. CENSUS TRACT <br /> Owner's Name � � Phone s=U2,2-- <br /> Address <br /> Address6L&_1_11 city , <br /> Contractor's Name Z /U E? ,� ' ,p License # Phone�j } <br /> TYPE OF WORK W(Check): NEW WELL ./ DEEPEN -/-7 RECONDITION /_7 - DESTRUCTION f 7 - { <br /> M PUMP INS�TION PUMP REPAIR PUMP REPLACEMENT <br /> Other /_7 <br /> -- <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 S1 <br /> Industrial Cable Tool Dia. of Well Excavation yS'�<< <br /> Domestic/private Drilled Dia. of Well Casing = a , <br /> Domestic/put lic,- - R - �Dr- iven. . ., , w;. ..Gauge of--Casing <br /> Irrigation X Gravel Pack Depth of Grout Sear <br /> Cathodic Protection Rotary Type of Grout. "' �i <br /> Disposal Other Other-Information ' <br /> -Geophysical Surface'Seal Installed 'B : jr <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump i H.P. S` <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,REPAIR: r =/_=/ State-Work Done <br /> llES•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 /> ..rJ _,+.--,. � q,_ �. <br />, iid"the Stafe�of Cal3forziia p�` ertain3ngto or regulating we ''constructionwsr. W_.�„ithin FIEEN 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 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 ARO NG 4ED A FIMb INSPECTION. <br /> SIGNED _ W TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL'COMMENTS: s <br /> P E ,, QAOUTV INSPECTION PHASE I aINAL INSPECTION <br /> INSPECTION BY DATE /�-r`1 � INSPECTION BY DATE <br /> i E H 1426 Rev. 1-74 —4 Z-75_ 2M <br />