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SAN,-,60A DIN LOCAs, HEALTH DISTRICT <br /> FO OFFICE USE: 601 E� Haz-lton'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _g5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2:2_-7-76 <br /> { S 7 cftf c..o Iv E. 7W-&-,C=- -AL'-O' (Complete In Triplicate) ��o,J: Z2� - 09'0-e'7 <br /> n Joaquin Local Health District far a permit to construct <br /> Application is hereby made to the Sa <br /> and/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 ', � 1414 CENSUS TRACT <br /> Owner's Name Phone <br /> Address 7 City <br /> Contractor's Name <br /> License 46 Phone `,7.? <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ I RECONDITION /? DESTRUCTION /— <br /> _ I <br /> PUMP INSTALLATION '/ PUMP REPAIR PUMP REPLACEMENT � iI <br /> t <br /> Other I I w <br /> DISTANCE TO NEAREST: SEPTIC TANK �! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHE <br /> PROPERTY LINE - PRIVATE, DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> �i <br /> Dia. of Well Casing <br /> _ Domestic/privateDrilled - <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout SealV7 I <br /> Cathodic Protection Rotary Type of Grout <br /> Other _ Other Information 1 <br /> _Disposal 1 <br /> T Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of.Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> tate. Work .Done ,.. <br /> PUMP REPAIR:-- - � s S- _ �_ �... <br /> T Approximate Depth ^ <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> k and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY41 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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-1 <br /> PRIOR TO GROUTING' AN INAL IN ECTIO <br /> SIGNED ITLE <br /> .1 <br /> ' T' LAN ON RE SE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHA I I/RINAL INSPECTION <br /> FHA II OU,T. INSPECTION DATE <br /> INSPECTION BY DATE .2 INSPECT <br /> BY <br /> 3/ <br /> 76_ `4i <br /> I� E H 1426 Rev. 1-74 <br />