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.. SANS JOAQUIN LOCAL HEALTH DISTRICT <br /> FOsi3OFFICE USE: :11601 EHazelton Ave. , Stockton, Calif. <br /> ' •i' ►"Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76��?"0446 <br /> �' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ripplication 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 ,R�}le®' and Regulations of the San Joaquin Local Health Diet°riot. <br /> /_ <br /> A25ao, Av.'r +oe .. t'v 4 <br /> JOB ADDRESS/LOCATION —Ze;;Q- _ -aSTczSi a i { CENSUS TRACT " <br /> Owner's Name `�� Phone <br /> Address <br /> Contractor's Name ' #/4j� �Phone ��g�af� <br /> L TG ' License <br /> TYPE OF WORK (Check) : £ NEW WELL /7 DEEPEN '/7 RECONDITION 1-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION -/—/ PUMP REPAIR '/ / PUMP REPLACEMENT /7 i <br /> Other Ll t . <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 WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. 'of Well Excavation d ; <br /> Domestic/private Drilled- Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1 � <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed 'By:_ .. ..�. a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. , <br /> PUMP REPLACEMENT /r./ State Work Done <br /> PUMP .REPAIR: State -Work-Doi <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 AND A FINAL INSPECTION. <br /> SIGNEDa TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FCA EPARTMENT USE ONLY <br /> PHASE I r_7-D_ <br /> Rn <br /> L� <br /> AP, P�LIC.ATION ACCEPT fDATE <br /> ADDITIONAL CO S: <br /> P $ I UT INSPECTION t NAL INSPECTION <br /> INSPECTIaN DATE .YNSPECT DATE <br /> E H 1426 Rev. 2-74 h�M. <br />