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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -i—OF-"OFFICE USE: j; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76y3Ffi�V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b-19-2,(, <br /> (Complete In Triplicate) <br /> Application is hereby made to the 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. <br /> JOB ADDRESS/LOCATI(.N ' _ CENSUS TRACT <br /> Owner's Name ��� � )9(rA4 � 7'� � � Phone <br /> Address 2 �'�, �`"` t''._,_.,—. City 1-6 <br /> Contractor's Name�D�., 4- License #16 >9'?-Phone 1,24U <br /> -r -i- <br /> TYPE OF WORK (Check) NEW WELL /ii/�DEEPENH/ /_ RECONDITION /_/ r DESTRUCTION /_7 <br /> PUMP INSTALLATION'—PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other l <br /> If <br /> DISTANCE TO NEAREST: SEPTIC TANK j1S> SEWER LINES 6 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE :.1 TYPE OF WELL CONSTRUCTION SPECIFICATI90S � t <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven : Gauge of Casing 1 7- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection � Rotary Type of Grout _ r <br /> -- + <br /> Disposal q Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor _._ ..._.�•�_1-- 'T�" �U�f' -J ._ <br /> Type of Pump L-� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />` PUMP .REPAIR:­�� ��� State-Work Done <br /> PES-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 of California pertaining to or regulating we11 '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 of3,the well and notify them before putting thewell in use. The above <br /> %information is true-to.-the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECT <br /> PRIOR TO GROUTING AND AirFINAL INSPECTION. <br /> SIGNED , . „✓ TITLE <br /> !I ((DRAW—PLOT PLAN ON REVERSE SIDE) <br /> j' FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE ? <br /> ADDITIONAL COMMENTS: I9 <br /> PHASE II GROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY ,I DATE INSPECTION BY DATE �G� j <br /> E H 1426Rev. 1-74 <br /> 3/76 2M <br />