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S" JOAQUIN LOCAL HEALTH DISTRICT <br /> O_S OFFICE USE: 1601 Hazelton Ave. , Stockton, Cal_ _ . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76-96 714 <br /> "THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication is hereby made to the Sar. Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquir <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION j. �i'� �►"' ��,u,,, ;?�, �,�,�`, �� CENSUS TRACT <br /> aner's Name <br /> e d� y4 -- - - Phone <br /> 1dress f'i��/ v -(�. c (� City <br /> )ntractor's Name �,. / ( , LicensePhone <br /> (PE OF WORK (Check) : NEW WELL /c ' DEEPEN / / RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /y/�PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other <br /> [STANCE TO NEAREST: SEPTIC TANK Z�2 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 2j!9r CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY DINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATICNS "1) <br /> Industrial ____,,,- Cable Tool Dia. of Well Excavation <br /> ,�omestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation �^ Gravel Pack Depth of Grout Seal e)� <br /> Cathodic Protection Rotary Type of Grout 7 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> TMP INSTALLATION: Contractor '272 \ <br /> Type of Pum; H.P. <br /> TMP REPLACEMENT: / / State Work Done <br /> TMP .REPAIR: / / State Work Done <br /> S TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ld the State of California pertaining to or regulating well *cons�ruction. Within FIFTEEN DAYS <br /> :ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> :LL DRILLERS REPORT of the well and notify them before putting the well in use... The above <br /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING ANDA FINAL INSPECTION. <br /> =GNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> {ASE I <br /> 'PLICATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: o w <br /> PHA T INSPECTIO P NAL INSPECTIOtT <br /> ISPECTION BY DATE - - INSPECTION BY DATE <br /> 77 <br /> E H 1426L" kev. 1-74 �to-�U/�C�. T'� who �i h/75 2M <br />