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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. /�- <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;76'—S !v <br /> 7,4-8g! PO <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> II <br /> 1 (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 deaei ibed. 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 /> fl <br /> r JOB ADDRESS/LOCATION �; _ m c� 1!�®" ✓ �'" - - — CENSUS TRACT <br /> Owner's Name A�2 46 <br /> Phone d <br /> k Address /CL C/GG./� C9 -7 City <br /> . Contractor's Name .��Q License dhone � /� <br /> � t _ <br /> f l <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / CONDITION / / DESTRUCTION <br /> { ` <br /> PUMP I INSTALLATION Ad PUMP" REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> 1 <br /> I DISTANCE ;TO NEAREST: SEPTIC TANK.�_f SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLT ODOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION.OSPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation a � <br /> Domestic/private Drilled Dia. of Well Casing (� <br /> Domestic/public _ Driven .Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection ,k Rotary Type of, Grout <br /> ` Disposal Other Other Information i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type, of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / /' state Work Done <br /> G DESTRUCTION OF WELL: Well Diameter Approximate Depth T <br /> Describe Material -and-Procedure <br /> _.� P«,. <br /> I hereby agree to comply''with- all lawsland regulations of the San Joaquin Local Health District <br /> and the State of California perthningkto or regulating well'.construction. Within FIFTEEN DAYS <br /> after completion of my wor inew well,-7, furnislithe#San Joaquin Local Health District <br /> WELL DRILLERS REPORT the we11#and notify them before putting the .well in use. The above <br /> information is Py to thejNmrt-tTm .know_jpdge and belief. I WILL CALL FgR A GROUT INSPECTION <br /> PRIOR TO GRO FIN NSP IO <br /> SIGNED �� - TITLE <br /> °+ DRAW Pig"ZT PLAN 'ON REVERSE SIDE) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A I <br /> Q, r <br /> APPLICATION ACCEP D B DATE.. <br /> rt G ©LS <br /> ADDITIONAL COMMENTS: !i <br /> ,. PHASE II GROUT INSPECTION yam► ' PRASE I .:I F_ 1NAL INSPECTION <br /> INSPECTION B Y '1 DATE ">� a «INPCTION•"=BX- DATE <br /> i 3/16 2M <br /> r E H 1426 Rev. 1-74 <br />