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s <br /> _ 10 V1 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. 76-/lg6J�, <br /> ,I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 22-2-T7,4 <br /> (Complete In Triplicate) �Z_to l-/"ZO- 05 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a �,?um� � ��S, `�� hY1S�/s �/u CENSUS TRACT �S <br /> I <br /> Owner's Name 0" s d Phone <br /> �G ry <br /> Address / " �J "a_a 'O`n-.G City � �•� <br /> Y � <br /> Contractor's Name � License -Phone 2--26,26 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_ RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION /—/ PUMP REPAIR Z -PUMP REPLACEMENT- /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT OTHER J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ^D. ; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing oQ <br /> 4 Domestic/public Driven Gauge of Casing i <br /> F, Irrigation Gravel Pack Depth 'of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ; <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor� a4. <br /> Type of Pump _ `Z:�,4 J47 AV H.P. d <br /> PUMP REPLACEMENT: / / State .Work Done <br /> PUMP .REPAIR: lXl State Work Dona <br /> DES: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 /> and the State':,"af California pertaining to or regulating well•construction. Within FIFTEEN DAYS <br /> after completion- ofmy 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 b s f mynowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FI S t1N <br /> SIGNEDe_ yitoee�K� A> ITLE ��' . <br /> (DRAW P PLAN ON RSE .SIDE <br /> OR TMENT/USE ONLY <br /> PHASEI Pico <br /> APPLICATION-. ACCEP D-B3C :` �.� DATE ZZ� - <br /> ADDITIONAL'�COMMENTS: <br /> PHASE II RROUT INSPECTION PHASE III/FINAL INSPECTIO <br />,. INSPECTION BY DATE INSPECTION BY DATE I.;,-V-7-6 <br /> • <br /> " 3/76 2M <br /> ,, �;.;H 1426 Rev. '1-74 . : � - <br />