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r) E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFI� CE USE: 1601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4-r <br /> 76 7/P <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE -ISSUED Date Issued ,y,," <br /> (Complete In "Triplicate) <br /> .Application is' hereby mane to the San Joaquin Local llealth 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 acid' the Rules and Regulations' of the San 'Joaquin Local Health District. ) <br /> JOB ADDRESS/LOCATIONGENSUS TRACT i <br /> Owner's Name 4 Phone ' env c-77!2S''` <br /> Address , . - Gat .. <br /> y . . <br /> W''``��� i <br /> Contractor's Name � [� .SS_� �� � � ' � License # o g Phare .Z - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN' -? RECONDITION,f7 DESTRUCTION �I <br /> PUMP INS AL TION" PUMP REPAIR.MPUMP REPLACEMENT 17 ^� <br /> Other . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ �_ OTHER <br /> PitOPERTY LIME - PRIVATE DOMESTIC WELL'_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G' <br /> Industrial _'Cable Tool Dia. of Well Excavation Ca <br /> Domestic/ rivate <br /> p Drilled Dia. of Well Casing . <br /> Domestic/public Drives Gauge of Casing <br /> - <br /> Irrigation .,::...__ ..� - GravelPack- Depth 'of Grout <br /> Cathodic Protection Rotary �.�Type-of Grout --� <br /> Disposal- Other Information" <br /> Geophysical.. . Surface_Sea1_In2lgUeid ly.' <br /> PUMP INSTALLATION Contractor <br /> Type ,of Pump _ 'R.P. <br /> PUMP REPLACEMENT: L7 State Wark Done <br /> PUMP REPAIR: - ` z State Work Done` ����' ' - ""•• �- <br /> PESiRUCTION 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 -FDR-A'GROUT INSPECTION <br /> PRIOR TO GRAUTING 'AND A FINAL INSPECTION. <br /> SIGNED ITLE <br /> RA PLOT P12N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Y <br /> APPLICATION ACCEPTED BY m' _ ' DATE ' -4 ] d <br /> ADDITIONAL E7aMMENTS t <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATM <br /> E'H' 1426 Bev. 1-74 - r- .a _ 2M <br />