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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOE.OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. d <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.79-1/0 q. <br /> ' <br /> � pt THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date-Issued,5-/ -?- <br /> �[ (Complete In Triplicate) ' I <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application ismade in compliance with San Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dist4 ct. <br /> JOB ADDRESS/LOCATION, r , CENSUS TRACT <br /> Owner's Name ' c4 ! d`O / Phone a <br /> Address � City c { <br /> Contractor's Name License It. hone <br /> TYPE OF WORK. (Checkf)� NEW WELL DEEPEN '/_/ RECONDITION / / DESTRUCTION /_7 I <br /> PUMP INSTALLATION 6< PUMP REPAIR J / PUMP REPLACEMENT /? <br /> q11 / Other <br /> M1 �Q <br /> DISTANCE TO NEAREST: SEPTIC TANK p EWER LINES f�j> PIT PRIVY v <br /> SEWAGE DISPOSAL FIELD l�D -It 4M <br /> PIT �_ OTHER V <br /> PROPERTY LINE15LPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED U$'E TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial,r Cable ToolDia. of Well Excavation Z O W. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Gauge of Casing <br /> Irrigation Gravel 'P ck.",\ * ,,. Depth of Grout Seal d <br /> Cathodic Protectionp Rotary -Type of Grout <br /> Disposal Other Other Information , <br /> Geophysical rSurface Seal Installed By: /1'6rx <br /> PUMP INSTALLATION: Contractor,, '" <br /> Type' of, Pump c e. asy.� v H.P. - <br /> PUMP REPLACEMENT: •' P/; State Work Done � E <br /> PUMP .REPAIR: ,�3 <br /> / / State Work Done <br /> DESTRUCTION OF' WELL:` Well Diameter <br /> 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 'Cali-fornia 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 e well and notify them before putting the well in use. The above 1 <br /> information is true o the best ofmy k owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NSP ocT <br /> SIGNED TITLE <br /> ! (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY � <br /> PHASE I <br /> APPLICATION ACCEPTED Y. }.• E 6M &Zz� DATE <br /> ADDITIONAL COMMENTS. r' . .. a N <br /> PHASE II GROUT INSPECTION P S AL INSPECTION <br /> INSPECTION BY- DATE S_ %_11 INSPECTION BY DATE <br /> E H 1426 RRu. 1-7L - J.11177- 2M <br />