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IGv SAN JOAQUIN LOCAL- HEALTH- DISTRICT RR' <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 4 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2L= 791 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-3D-76 1 <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. 186/2G and Lthe Rules and Regulations of the San Joaquin 'Local Health District. <br /> JOB ADDRESS/LOCATION / v J3 S 6X �a x,� CENSUS TRACT <br /> " <br /> Owner's Name , �J At D a-so ez/ _._..__-•- Phone. <br /> Address i4 City ec—s< <br /> Contractor's Name acJc/ D License Phone ' $3S-;��7 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION.'/ / PUMP REPAIR /' PUMP REPLACEMENT /7 <br /> Other <br /> r •-• I <br /> DISTANCE TO -NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' ` • SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r _ 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 f_ ' • 'Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> -Disposal Other Other Informationm <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done fC7l <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 FQ4 A GROUT INSPECTION <br /> PRIOR TO GF.OUT .NG AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PMT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/F AL INSPECTI N ` <br /> INSPECTION BY DATE INSPECTION BY DATE '' <br /> 4 <br /> E H 1426 Rev. 1-74 3/76 2M <br />