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`N JOAf_")UIN LOCAL HEALTH DISTRIr" G <br /> F01 OFFICE USE: 16 _ E. Hazelton Ave. , Stockton, C, f. <br /> Telephone : (209) 466-6781 <br /> APPLICATION, FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z',_,7,j ki <br /> — 7� <br /> THIS ?'ER-MTT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 76 96 <br /> Gn-Q <br /> (Complete In Triplicate) <br /> Application is Hereby made to the S;Ar, ,I:iaquin Local Health District for a permit to construct <br /> and/or install the work hexc.ia describ�:d. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> s . <br /> `� G`: <br /> Owner's Name i f/ �._-�. �*--���..._a.�.-_ - - Phone <br /> Address <br /> OL 4-1 5 ['` /'� � . ( .�C,c _ City <br /> Contractor's Name �c f/I:. License � 'iE' Phone <br /> TYPE OF WORK (Check) : NEW WELL /c-/ DEEPEN /—/ RECONDITION /—[ DESTRUCTION /_7 <br /> PUMP INSTALLATION /l:7-71?UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7.0 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 <br /> ' Domestic/private <br /> Drilled Dia, of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal O% <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> -- <br /> Geophysical Surface Seal Installed By: ./,. , <br /> PUMP INSTALLATION: Contractor <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 /> 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 ANDA FINAL. INSPEC ION. <br /> SIGNED iXT 777, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: � <br /> PHA �T 1NSPECTIO10 PHW NAL INSPECTIO , <br /> INSPECTION BY DATEINSPECTION BY DATE / <br /> E H 1426 =' � �7 �r✓o ,� ��,,,�,,,{ �,'�� �'�,'� . <br /> �tev. 1-74 ,?vr�4li/zC/. T�ih w.U'a ,�d�� 1,/7K 9M <br />