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_ - SAN :J'OAQUIN• LOCAL HEALTH DISTRICT <br /> FOSiOFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephoine: (209),, 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7d_lhs yJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _rS=76 <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 Joaquix <br /> County Ordinance 'No. 1862 aAd the Rules and Regulations of the San Joaquin Local Hulttj District. <br /> A16 <br /> ��JOB �S/LOCATION CENSUS TRACT <br /> Owner's Name AAPhone <br /> Address 0�_ZlzzQ VZGz`' ��/ City <br /> F J <br /> Contractor's Name ee --U,94 A ��*-.S_Licensew one <br /> 1 � f <br /> i <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPENS/? RECONDITION / DESTRUCTION rT <br /> PUMP' INST LATION f PUMP REPAIR J7 PUMP REPLACEMENT l"T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -�-- <br /> SEWAGE DISP AL FIELD CESSPOOL/SEEPAGE PIT/Q� OTHER <br /> PROPERTY LINE-9-5PRIVATE DOMESTIC WELL 4L�Le) PUBLIC DOMESTIC WELL — <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> i Domestic/private 1:::Drilled, Dia, of Well Casing <br /> Domestic/public v `. Drivel 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 /> 1 <br /> PUMP INSTALLATION: Contractor i <br /> Typed of Pump � H.P. � <br /> k :I <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP '.REPAIR. /7State Work Done <br /> QES-_TRUCTION 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 FOR'A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDFi - _ - <br /> ---- P -P -ON-REVERSE-SIDE <br /> �. FORD ARTMENT USE ONLY <br /> PHASE I 4 <br /> APPLICATION ACCEPTED BY -- _� _ ___�-- - -- -DATE <br /> ADDITIONAL 'COMMENTS: <br /> P E II GROUT INSPECTI N PHASE II JINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ?. <br /> �42ME H 1426 Rev. 3-74 <br />