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5�JT 711, AO <br /> �t <br /> qd oIPI <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- .4 9#.,�) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCATION CENSUS TRACT <br /> Owner's Name Phone q31- 1033 <br /> Address t�,I� City <br /> Contractor's Name �p� h4 License # Phone 1- l 22- <br /> TYPE <br /> ZTYPE OF WORK (Check): NEW WELL,,/PEN /7 RECONDITION DESTRUCTION . <br /> �j <br /> PUMP INSTALLATION _7 PUMP REPAIR /�_PUMP REPLACEMENT 17 <br /> Other E7 Y . <br /> DISTANCE TO NEAREST: SEPTIC TANK— SEWER L NES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD Z CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL_' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT S <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing-..._. <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation _ Gravel, Pack , Dep,tA of Grout Seal <br /> Cathodic Protection _Rota-ry,.,�__,., _f Type of Grout <br /> Disposal Other Other Information , <br /> Geophysical Surface Seal Installed B- ' <br /> PUMP INSTALLATION: Contractor --��� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: <br /> State Work Done <br /> ES TRUCTION OF WELL: Well Diameter, Approximate Depth <br /> Describe Material and Procedure y. . . <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 'constructlon. -Within FIFTEEN DAYS <br /> after completion of my work on a new well, i will furnish the San Joaquin Local Health District a <br />'TELL 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 GROU N AND A FIN NSPECTION. <br /> SIGNED <br /> TI'PLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> n <br /> AP ILP CATION' ACCEPTED BY /& DATE �v <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE J rINSPECTION BY DATE <br /> E H 1426 Aev. 1.-74 rd ie$ /77 rw a�►��r 7� .i��7`a!/ ��` ", ��,�� �7�, � <br />