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SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> FORfOFFICE USE: _1601 E. Hazelton Ave. , Stockton, Calif., <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR'MELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-S"7L�J <br /> THIS PERMM EXPIRES 1-YEAR FROM DATE ISSUED Date Issued <br /> (Complete In 'Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br /> end/.or install 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 District. <br /> JOB.ADDRESS/LOCATION WA 77202ei 9b CENSUS TRACT <br /> Owner's Name Phone <br /> Address - City Fie 16 A)G 4 <br /> ® AX 316 �,Af�1yt�NG`ni <br /> Contractor's Name'-- --- z3AB 13License'!# k 3 c 2 Phone!R <br /> r <br /> TYPE OF WORK. (Check): NEW WELL- /17. . DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 <br /> _ PUMP INSTALLATION- /% PUMP REPAIR /� PUMP REPLACEMENT /7 <br /> Other /7 <br /> .'DISTANCE TO NEAREST: SEPTIC TANK 'go at, SEWER LINESZ&A PIT PRIVY I - <br /> j SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTHER <br /> PROPERTY=LINE1A PRIVATE DOMESTIC WELL PUBLIC MMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION]SPECIFICATIONS <br /> -Industrial . <br /> .Cable Tool Dia. of Well Excavation o Ilk <br /> =Domestic/private Drilled. Dia. of Well Casing :P_. <br /> Domestic/public � . Driven ` Gauge. of_Casings P4.1 C, <br /> F' <br /> Irrigation` /Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _Rotary Type of Grout E 7' <br /> ,Disposal Other Other Information - T <br /> Geophysical Surface Seal Installed BY: AL.Elf- <br /> PUMPP INSTALLATION: Contractor <br /> w.Type ofPump. H.P. <br /> PUMP REPLACBIMT: L� State Work Done <br /> "PUMP :REPAIR: L7 State Work Done r <br /> ,pESRUCTYON 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 , s' <br /> after completion of my work on a new well, 'I will furnish the Sao, Joaquin Local Health Distrix e <br /> ryWELI; DRILLERS REPORT of the well and notify 'them before putting. the. well in-use.. The above <br /> Informatiah 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. ___ w <br /> SIGNED TITLE: '- D <br /> 2RAW PLOT PLAN 'ON REVERSE SIDE:- <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GOW IXSECT PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE —7-7 <br /> E H 1426, Rev. 1-74 1_74 2MQ4�3. <br />