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iy <br /> f <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT r <br /> FOE OFFICE USE: V04000,1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.76- 5221 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct G <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'.Distri-ct. - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NamePhone <br /> -Ay-.,Z- M/ Z919 �. <br /> Address '54 ,5,0 City <br /> Contractor's Name � ^ License #11;_11_L Phone ' � <br /> .. 1 <br />,.TYPE. QF WORK (Check) : NEW WELL DEEPEN /�% RECONDITION S/�~' DESTRUCTION f� <br /> PUMP INST LATION '/ / PUMP REPAIR/ / PUMP REPLA MENT /? <br /> Other /P <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation f <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public , Driven Gauge of Casing <br /> Irrigation Gravel -Pack -' Y_...Depth..of.Gro.ut_.Seal_ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ° Other Other Information <br /> -- Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor j <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE 44 A <br /> { ,(DRAW-PWT' PLAN 'ON RE <br /> -- FRSE SIDE -- --- - <br /> DEPARTMENT USE ONLY <br /> PHASE Tf: ' 7 <br /> APPLICATION ACCEP ® - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASf III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE J� <br /> 2M <br /> E H 1426 Rev. '1-74 <br /> 3/76 <br />