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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: C 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. uJ <br /> • 76-770}� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?-,.a-2Z <br /> (Complete In Triplicate) <br /> Application is hereby made to tle. 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/LOCATION t CENSUS TRACT <br /> Owner's Name Phone 16 <br /> �JL <br /> Address Q City xL o-� <br /> Contractor's Name /! License ���(�2.323_ Phone <br /> TYPE OF WORK (Check) : NEW WELL ', DEEPEN /_7 RECONDITION I-T DESTRUCTION %T <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / j <br /> -DISTANCE TO NEAREST: SEPTIC TANK / 'SEWER LINES PIT PRIVY <br /> 4", SEWAGE DISPOSAL FIELD Z6o ' CESSPOOL/SEEPAGE PIT laa 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 i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pace Depth of Grout Seal <br /> Cathodic Protection %Rotary �f'A;T Type of Grout N <br /> Disposal Other ;' - Other Information ' <br /> Geophysical L .1 Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor �✓�- , �" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: z Ll State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter- Approximate- Depth - '- <br /> Deseribe)Iatier-ial and Procedure - . <br /> I hereby ag e, o_pomply w... th�a11laws--and__regula,tions :o.f:�the'EabLJoaquin__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 Locl'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 GRO NG D A FIEL INSPECTION. <br /> SIGNED /'I.a - - TITLE j <br /> D W PLAN 'ON E S IDE <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE I �r ! <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: U <br /> 77 � <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATES <br /> E H 1426 Rev. 1-74 V76 �+h' <br />