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7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> FOF OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. ,. <br /> Telephone: {209), 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued X76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> is made in compliance with San Joaquin <br /> and/or install the work herein described. This application <br /> the San Joaquin Local Health District. <br /> County Ordinance No. 1.862 and the Rules and Regulations of <br /> f r _ CENSUS TRACT <br /> JOB ADDRESS/ i '� <br /> Phone <br /> Owner's Name <br /> City <br /> Address <br /> i 112�u License hone <br /> Contractor's Name <br /> TYPE-GF"WORK-(Check)": `NEW WELE ' V"' DEEPEN-r/-_/ RECOi3i l' ION:] I DESTRUCTIbN J _ <br /> PUMP INST�LATION / / PUMP REPAIR'/ / PUMP REPLACEMENT <br /> Other / 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK / U SEWER LINES �(q F`PIT PRIVY <br /> SEWAGE DISPOSAL IELD.�� CESSPAOL/SEEPAGE PIT/C9 c r" OTHER <br /> '" PROPERTY LINE PRIVATE DOMESTIC WEL1,fU�tPUBLIC DOMESTIC WELL' <br /> INTENDED USE TYPE OF WELL 11CONSTRUCTION 4 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool #' \Dia. of Well Excavation t� <br /> Domestic/private Drilled ,z., Dia. tof Well CasingF:::4 <br /> Domestic/public Driven E Gauge of Casing f <br /> Irrigation Gravel..,Rack,� �Depth of Grout Seal <br /> Cathodic Protection Rotary'tType of Grout <br /> LF <br /> Other � Other Information Disposal 0 `-` Surface Seal Installed BGeophysical PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> I . �... _State-Work -Done ��..•.,,.,�.�`_ ��.-��--�-1-ms-µ_- .._.�.,_._.:.:r- - <br /> PUMP .REPAIR'—_. ;,,,� ::, _. //�.�. ¢._.__ -� <br /> DESTRUCTION OF WELL: --Well..Diameter. 4 _ _ Approximate Depth <br /> Describe Material and :Procedure •� <br /> I 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> F SIGNED ITLE <br /> -- ;,, is <br /> ' T P AN ON REVERSE SIDE) <br /> OR P TMENT USE ONLY <br /> PHASE I , DATE <br /> APPLICATION ACCEPTED <br /> N6Lb WELL- <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION �' DATE <br /> INSPECTION BY r�' - DATE 2 - 76 INSPECTI BY <br /> 3/76 2M <br /> I <br /> �. E�Ii 1426 ' Rev.. 1=74.E-T., <br />