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\00� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TO-E OFFICE USE: K_V1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: -(209)\466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 6-1-� w <br /> ` THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 'F Application is hereby made too the San Joaquin Local health District for a permit to construct <br /> l' and/or instar the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATICr J-17 / ralI l° �7 CENSUS TRACT <br /> Owner's Name L- A Hd it Phone�. <br /> ` til & Z n City r C1i Df� <br /> Address / y �� r <br /> Contractor's Name I !( License #V!` Phone4q�-AA f1' <br /> K TYPE OF-WORK (Check) : NEW WELL DEEPEN J RECONDITION /7 DESTRUCTION /7 <br /> PUMP 'INSTALLATION / / PUMP REPAIR./7 PUMP REPLACEMENT CT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial LX Cable Tool Dia. of Well Excavation—IT-- <br /> -_-'Domestic/private Drilled Iiia. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection •Rotary Type of Grout&44 <br /> Disposal Other . j'Othe-r-Information +' <br /> Geophysical. Surface Seale Installed-Bj : <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> 'UMP"REPLACEMENT: • <br /> L_/ State-Work Done - <br /> PUMP .REPAIR_: -�- /. / StaCe Work ,Done . f <br /> DESTRUCTION OF WELL: Well.#Diameter � Approximate=Depth <br /> Describe Material and Procedure 1f <br /> I Hereby agree to comply with all laws and regulations of the Han Joaquin Local Health' District <br /> and the State of California pertaining to or regulating well ,'con.struetion. 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.w6ll. in.use.... The above <br /> information is true to the-best".of- my..knowledge and belief. I-WILL CALL FOR A GROUT INSPECTION <br /> t PRIOR TO GROUTING ri NSPECTION. <br /> SIGNED -�..r ._ - _"`�'�"- TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> k APPLICAT N ACCEPTED BY DATE <br /> ADDITIO AL CO <br /> P I OUT INSPECTION PIAS III INAL INSPECTION <br /> INSPEGTI DATE INSPECTION BY ATE <br /> 2 F H 1A26 Raw- 7_7G - �l . � � � <br />