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j �/, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7686 y-!* <br /> i 76-//6 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San. 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 Regulationss/of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2- f i� .r dt Z'11r J CENSUS TRACT <br /> Owner's Name /ri Phone <br /> Address City <br /> ALicense Phone A. <br /> Contractor's Name I <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /7/ RECONDITION /7 DESTRUCTION- /? <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other '/ / <br /> DISTANCE TO-NEAREST: SEPTIC-TANK4_C—dP f_SEWER­LINES• •d SPIT PRIVY--- <br /> SEWAGE <br /> RIVYSEWAGE DISPOSIELD �' CE55POOL/S EPAGE PIT /d� OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WEL ""PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \n , <br /> Industrial - •' + � Cable Tool Dia. of Well Excavation f9c�t <br /> Domestic/private /v Drilled Dia. of Weil"Casing 410 z JA"wv h ; <br /> Domestic/public Driven Gauge of Casing ` <br /> Irrigation i Gravel Pack Depth of Grout� Seal v # <br /> Cathodic Protection Rotary ` �_ Type of Grout ! <br /> Disposal ' Other Other Information"' i <br /> Geophysical Surface Seal­,Installed By: <br /> PUMP INSTALLATION: Contractor kip Q S # <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP .REPAIR: / / State-Work Done <br /> DESTRUCTION OV 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 /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> k 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 INSPECTION. <br /> �� � <br /> SIGNED' T .: <br /> D PL T L 0 REVERSE SIRE) <br /> F R DEPATMVkT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT AfA DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE .IT GROUT INSPECTION PHASE,II7�/FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1.-74 _ -- -- <br />