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AQUIN' HEALTH DISTRICT <br /> LOCAL HE .�. <br /> SE: <br /> FOE:OFFICE <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76'- Y S/" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED — <br /> Date Issued .S`--/ _76 <br /> (Complete In Triplicate ^ <br /> ) � w � <br /> Application Is hereby made to the Sari Joaquin Local 1jealth District for a permit to �onstruct <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 /> 72-s� S. <br /> JOB ADDRESS/LOCATION <br /> r^ CENSUS TRACT _ <br /> Owner's Name <br /> Phone <br /> Address w S <br /> City _ _��41, <br /> �� <br /> Contractor's Name paw <br /> PSI�. <br /> License # O-Z-7?d Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN •/? RECONDITION <br /> L7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR -%) Pump REPLACEMENT /f <br /> Other <br /> DISTANCE TO NEAREST: SEPSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PICT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED_USE TYPE OF WELL <br /> _ Industrial CONSCable Tool Dia. of Veil TExcavatton <br /> ECIFICATIONS <br /> RUCTMV <br /> Domestic/private <br /> _ <br /> Domestic/public Drilled Dia, of Well Casing <br /> Driven Gauge of Casing i <br /> Irrigation ^ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection� Rotary Type of Grout <br /> Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. 4 <br /> PUMP REPLACEMENT: State Work Done k <br /> - _ <br /> PUMP _R State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth ' <br /> I hereby agree to comply with 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 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. <br />'RIOR TO GRO TING AND A FINAL INS ECT I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED 7­7_ _ - <br /> i jlf ITLE , <br /> D W PLOT P AN ON RERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> LPPL CATION ACCEPTED BY <br /> IDDITIONAL COMMENTS.* DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III FINAL IN5PECTION <br /> DATE INSPECTION BY <br /> DATE -7, <br /> E H 1426 Rev. 1-74 <br />