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�w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !/ <br /> FOF�;OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> +' <br /> Telephone: (209) 466-6781 + <br /> ell APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-78' tc� <br /> THIS PERMIT EXPIRES _1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In. Triplicate) r <br /> Application is hereby made to''the San Joaquin Local Health Distract for a permit� tq construct <br /> and/or Anstall 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 Di6ftict. <br /> ,.Irk <br /> JOB ADDRESS/LOCATION �G�Gy �11�/Pj CENSUS TRACT <br /> Owners Name 4 .= Phone IV-f- <br /> Address gie. City <br /> Contractor's Name .J a S. , > 4 Liedifie la Phone <br /> TYPE OF WORK (Check) : NEW WELL /P7 DEEPEN '/? RECONDITION %T DESTRUCTION f_77 <br /> PUMP INSTALLATION / / PUMP REPAIR '/? PUMP REPLACEMENT / r <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAII FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED' USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial I Cable Tool Dia. of Well Excavation l� " _ o { <br /> Domestic/private Drilled Dia. of Well Casing 6 }� G C:, <br /> x4 Domestic/public Driven Gauge of" Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otecion _� Rotary Type- of Grout.' <br /> Disposal Other Othex Information ..� <br /> Geophysical Surface Seal Installed By !1 <br /> PUMP INSTALLATION. Contractor <br /> r Type .of� Pump H.P. I <br /> PUMP REPLACEMENT: / / State Work Done ' { <br /> PUMP !REPAIR: / / State Work Done i <br /> IIES•TRUCTION OF WELL: Well Diameter Approximate Depth � I <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree to comply with h all laws and regulations, of .the.fSan,J.oaquin Local-.Health--District'-''j <br /> and -the-State- of-Calif orrfld�pertaining to or regulating well ','construction. Within FIFTEEN DAYS I <br /> after completion of my work on a new well, I will furnish the .San Joaquin Local Health District a J <br /> WELL DRILLERS REPORT of the well and notify thein before putting.the..wel1. in use.... .The above <br /> information is true to the best-of my..knowledge' and belief. I WILL CALL FOR A GROUV INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE �_�p�, _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II W9UT INSPECTION PRASE III FINAL INSPECTION � <br /> INSPECTION BY DATE -- INSPECTION BY 0 DATE <br /> E H 1426 Rev. 1-74 rr h/75 2M £ 1 <br />