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Rol- <br /> :OFFICE SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� USE: 1601 E. Hazelton Ave. , Stockton,- Calif. <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP, PERMIT Per No. 76-7674 <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED76 <br /> Date Issued <br /> (Complete In Triplicate) _ <br /> Application is hereby madelto the San Joaquin Local Health District for a .pe'rmit to construct <br /> + and/or install the work herein described. This application is made in compliance with San Joa u: <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sart -Joaquin Local Health District <br /> JOB ADDRESS l� <br /> ,CENSUS TRACT <br /> Owner's Name <br /> Phone ' <br /> Address :..�•. <br /> City <br /> Contractor's Name _ <br /> License hone <br /> TYPE OF WORK (Check) : <br /> NEW WELL DEEP - /? RECONDITION /-7 DESTRUCTION /7 <br /> k' PUMPtINSTALLATION // PUMP REPAIR /_ • PUMP REPLACEMENT /� <br /> x Otheic <br /> . . <br /> I. DISTANCE TO NEAREST: SEPTIC TRK SEWER LINES O PIT PRIVY �— <br /> SEWAGE DISPOS FIELD � � l�/S PAGE PITOTHER <br /> PROPERTY LINE/ RIVATE DOMESTICWELIfO '}`P.UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELT, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private " �( Drilled ,.. �. Dia. of Well Casing <br /> Domestic """�7"`"- <br /> /Public , w . .. - Driven <br /> f Irrigation _ Gauge of Casing — <br /> , Graver Pack Depth of Grout Seal � <br /> Cathodic Protection Ratan <br /> - ---- Y Type of Grout <br /> „_Disposal - Other Other.Information <br /> Geophysical ---w-�-- <br /> �-�Surface Sea Installed B <br /> PUMP INSTALLATION: ! <br /> Contractor _ �f/gyJS <br /> . 11 �Type `of Pump <br /> PUMP REPLACEMENT: ./ / State .Work. .Donet... <br /> r.' - - <br /> [ PUMPJREPATR: / / State Work Done <br /> # ' <br /> ---------------- <br /> j DESTRUCTION OF WELL: Well Diameter T <br /> Describe Material. and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEENtriDAYS <br /> f after completion of: my work on a newwell, 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 <br /> jPRIOR TO GROi1TTNG AND A FINAL`INSPECTIO GROUT INSPECTION <br /> SIGNED <br /> TLE . <br /> W PLO P ON REVERSE SIDE) 1A '01 <br /> PHASE I R DE TMLNT USE QNLY <br />; APPLICATION• ACCEPTED. <br /> ADDITIONAL COMMENTS: DATE -/Q- <br /> P 5 II G OUT IATE CTIO PHAS T I FI INSPECTIO <br /> INSPECTION BY DATE f (o INSPECTION BY <br /> DATE <br /> r �� , <br /> E H 1426 ` Rev. 1-74 -- r' .� GX, L1p <br />