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sAN`JOAQUIN LOCAL`REALTH DISTRICT "b <br /> POgrOFFICE USE: 16,0 'E.�,!Hazelton Ave.", Stockton, Calif. <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76= f Ll. -1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ;(Complete In Triplicate) <br /> Application is hereby made to�tha San Joaquin. Local Health district for a permit to construct <br /> 'and/or install. the work. here : described. -,-.This application-i made in compliance with San Joaquin <br /> County Ordinance No. 1862 and. the :Rules and Regulations.of the San Joaquin Local Health District. <br /> :JOB 'ADDRESS/LOCATION ' > L2�GG lCD/f� CENSUS TRACT <br /> Phone <br /> Owner's Nam <br /> Address <br /> City <br /> //7, 9� Phone-��� -3 <br /> License <br /> Contractor's Name f�.��.� <br /> • - <br /> TYPE OF WORK--(Check):v NEW WELL '/ 7 DEEPEN `/-7 RECONDITION /7 DESTRUCTION (7 <br /> PUMP INSTALLATION <br /> Other <br /> REPAIR /-7-Pm REPLACEMENT I I } <br /> Other / / j <br /> DISTANCE TO NEAREST: SEPTIC :TANK SEWER LINES _> PIT PRIVY <br /> SWAGE DISPOSAL FIELD ?: CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY..,LI-NE��- PRIVATE'-DOMESTIC.-WELL'- -:'�' --PUBLIC-DOMESTIC WELL <br /> ---' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/private {l Drilled Dia, of Well Casing <br /> Domestic/public H Driven. Gauge of Casing <br /> Irrigation `� fi Gravel Pack Depth of Grout Seal 4 ._ <br /> Cathodic Protection. Rotary° Type of Grout <br /> Disposal "*, Other .Other Information <br /> 'Surface Seal Installed B : <br /> Geophysical s;r <br /> PUMP INSTALLATION: Contractor ��* � <br /> Type bf PumpIlk <br /> - H.F. <br /> PUMP REPLACEMENT: / / 'State`Work Done <br /> PUMP `.REPAIR: /? 'State,Work Done i.. <br /> ES.-TRUCTION OF WELL: Well Diametet , 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 /> iafter completion of my worklon anew 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 /> f information is true to the.best of my knowledge and belief. I WILL CALL FOR A-GRQUT INSPECTION <br /> PRIOR TO G OUTING ANpA FINAL INSPECTION. . `.,,�.- ._.•.»- TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE�C� - - <br /> ADDITIONAL COMMENTS: j PHAS F NAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE //.ZSi' G INSPECTION BY 7 DATE <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />