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1 <br /> Araa <br /> 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"Nd,. T 76� <br /> 00 <br /> 0 THIS PERMIT EXPIRES 1 YEAR FRflM. DATE ISSUED Date Issued /-77 <br /> ' (Complete In Triplicate) g. . . , <br /> Application is hereby made: toithe-San Joaquin Local Health .District fora permit to construct <br /> and/or. install the work herein described. This application his mac;e. in... compliance with San Joaquin <br /> County Ordinance No. 1862 anV the Rules and Regulations oggS I asi Joaquin Local Health District. <br /> , <br /> yz /O A-1 <br /> Gt/� <br /> JOB ADDRESS/LOCATION Z 6oalg� <br /> Owner's Name eUc <br /> Phone V � � <br /> Address 47,S_7 6 1 ;�F L 0 U SE City oc <br /> ✓/ <br /> P f73 41'46 CMA <br /> Contractor's Name _ ,�ffVXA, _ �Vi License Phone <br /> TYPE OF WORK (Check): NEW WELL '/—T DEEPEN '/? RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSt LATION J / PUMP REPAIR '/_7PUMP REPLACEmmd /j <br /> Other i77 <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 t Cable Tool Dia. of We11' Excavation <br /> Domestic/private Drilled Dia. of Well Casing N - <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal . Other __ Other Information <br /> Geophysidal Y - Surface Seal Installed B . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: /_7 State work Done <br /> PUMP .REPAIR: /7" --State Work Done <br /> RE&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 ofCalifornia' 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 we11 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 GROUT AND A FIW INSPECTION. <br /> SIGNED TITLEfiU <br /> DRAW PLOT PLAN ON REVERSE SIDE F <br /> PHASEI FOR DEPART MEN USE ONLY <br /> - �� <br /> EN <br /> APPLICA_TION ACCE?TED BYY, Z/ DATE ' /~ 77 <br /> ADDITIONAL COMMENTS: :? <br /> INSPECTION BY PHASE II GROUT INSPECTI PHAS FIN TNSPECTI N �/ <br /> DATE INSPECTION BY DATE ff, `;. M <br /> - kI426A Rev. 1-74 r_ ._ )t/71� 0M_. . <br />