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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zd , <br /> 76-//3S"10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made{'tolthe 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. d <br /> // CENSUS TRACT <br /> JOB ADDRESS inc <br /> I�QdL Lit. <br /> Owner's Name ^� 6Y`e�`C Phone , <br /> Address City <br /> Contractor's Name Afft 9 License #2&zM4hone <br /> L <br />-TYPE-OF" WORK'-(Check) NEW WELL DEEPEN' / RECONDITION-/ / 'DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS IELD CESSP0 L/�S�EEtPAGE PI OTHER - <br /> PROPFRTY LIN�RIVATE DOMESTIC WELL f PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. I Cable Tool Dia. of Well Excavation , <br /> Domestic/private Drilled Dia. of -Well Casing <br /> Domestic/public 1 Driven Gauge of Casing Cn <br /> Irrigation 1 Gravel Pack Depth of Grout SealCathodic Protection 1 Rotary - Type of Grout t!:Disposal i Other Other Information <br /> Geophysical --- Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor M UVS <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> 9 <br /> PUMP .REPAIR: / / State Work Done _ <br /> DES-TRUCTION .OF WELL: Well Diameter Approximate Depth '. <br /> Describe Material and Procedure a <br /> I <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 GROUTING .AND A FINALr INSPECTION / <br /> SIGNED ITLE Iii✓ �t i <br /> P T P ' ON REVERS <br /> FOR DE ARTMENT USE ONLY � <br /> PHASE I <br /> f i <br />" APPLICATION ACCEPT 4L 494SE DATE "/f" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRAsE-41IA4FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Zf DATE <br /> - 3/76 2M <br /> E H 1426 Rev. 1-74 . <br />