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4,0 MA/ a4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO4�OFFIC USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> • Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-IS P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3.2it-26 <br /> (Complete In Triplicate) <br /> Application 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 ules and ],tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A41,4r4(7 CENSUS TRACT <br /> Owner's Namee C6 yR m t a&fob Phone 's <br /> Address //4 !� , � .J',a►f .��, City &o.IF est <br /> Contractor's Name ""' License #>9j 72- hone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /W—­PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other L 7 <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor �- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> PES-TTRUCTION 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 thewell 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 12=HgUTING AND A FINAL INS N _ <br /> SIGNED eu• ITLEr w,J' <br /> J�WAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY -- DATE -3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ;E H 1426 Rev. 1-74 1-74 2M <br />