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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ca <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit .No. 76--7/o 1.J <br /> "THI-S PERMIT_EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �1O�J76 <br /> C (Complete In. Triplicate) <br /> Application is hereby.made to the Sar: Joaquin Locai']tealth District fora permit to construct <br /> and/or install the work herein described. This app"Xication 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 /> Y <br /> JOB ADDRESS/LOCATION / CENSUS TRACT a . <br /> - 5 <br /> Owner's Name - <br /> Phone t< 7 e(5 6 (f <br /> 4 <br /> AddressCity <br /> Contractor's Name d License.. 4y 06 Phone3�..� <br /> TYPE OF WORK (Check) ; NEW WELL/Z7--DEEPEN J7 RECONDITION ~DESTRUCTION <br /> PUMP,. / IR INSTALLATION PUMP REPAJ / PUMP REPLACEMENT J f <br /> Other /j <br /> DISTANCE TO NEAREST: SEPTIC TANK e%o SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; <br /> PROFERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION;.SPECIFICATIONS <br /> Industrial A-7';Mib1e�Tool Dia;:. of. Well Excavation � <br /> t —Domestiu/private _Dii,lled. ' Dia... Of 611 'Casing ' <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation, Gravel Pack Depth of Grout Seal <br /> Cathodic-_.. otection"�_ '�- .Rotary Type of Grout- <br /> Disposal r-ether 4 0fherin.f0rmatioa r <br /> Geophysical Surface Seal Installed 'By:, <br /> A , r , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump G v.�. H.P. . ' 7 <br /> PUMP REPLACEMENT: • <br /> State Work Done <br /> PM !REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure :. <br /> I hereby agree to comply with all law's and regulations of the San Joaquin Local Health-District <br /> and the -tate of California pertaining to or regulating weli"canstruction� Within FIFTEEN DAYS j <br /> after completion of my work on a new well, I will furnish the San Joaquin I-ocal Health ''District a <br /> WELL DRILLER REPORT of the well and notify them before putting..the..well-,in.use.. The above <br /> information is true to the,best .af my..knowledge and belief. I WILL CALL' FOR ,, 'GROUT INSPECTION <br /> PRIOR TO GRO - AND A P SPECTION'. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DE <br /> PHASE I PARTMENT USE ONLY <br /> _ _ <br /> APPLICATION ACCEPTED BY `�" <br /> DATE <br /> ADDITIONAL>COMMENTS:' <br /> i� PHASE II GROUT INSPECTION ; x PHAS -II . INAL INSPECTION <br /> INSPECTION,.BY DATE '� INSPECTION BY IN DATE <br /> , . F.. . <br /> E H 1426 Rev. 1-74 .� . _-- <br />