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SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> FOE OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP Nwict No. 77�11�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> " (Complete In Triplicate) See Oe-•a 1°�'-•� �a 71-SS7e <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <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 kze6 `� CENSUS TRACT <br /> Owner'-s Name ts�.r,�. Phone <br /> Address City <br /> Contractor's Name 1A -f License # ( Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN,.:/�/`RECONDITION f ./ y DESTRUCTION. /_7PUMP INSTALLATION J_. / PUMP REPAIRY/ %—PUMRf,REPLACEMENT I� I <br /> -" Other J-7 <br /> DISTANCE TO DEAREST: SEPTIC TANK p- SEWER LINES PIT PRIVY. /D D <br /> tEWAGE DISPOSAL <br /> DOMESTIC WELLFIELD ��a# CESSPOOL/SEEPAGE PIT"-. ,- OTHER <br /> PROPERTY LINE <br /> _ _(0 PRIPUBLIC DOMESTIC WELL <br /> _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ► Cable Tool Dia, of Well Excavation 10 <br /> E rs p <br /> Domestic/private � . f�� Drilled Dia, .of We1l.,Casing <br /> Domestic/publicDriven Gauge...of; Casing <br /> Irrigation u _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout " <br /> Disposal. Other Other Information— <br /> Geophysical Surface Seal-Installed B : <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / /. ,.State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stat lifornia pertaining to or regulating well-construction. Within FIFTEEN DAYS <br /> after comp tion of y work on a new 11, I furnish the San Joaquin Local Health District a <br /> WELL DRIL RS REPOR of the well and o if em efore putting the..well in use. The above <br /> informati n' is u to a best of 1 and belief. I WILL CALL FO GROUT INSPECTION. <br /> PRIOR -TO ROU FINAL <br /> SIGNED .,�, TITLE <br /> W�'PL PLAN 'ON ETtSE SIDE f{ ' <br /> Pr ' -FOR DEPARTMENT USE ONLY <br /> PHASE I ��? � ;{ . .. .. <br /> APPLICATION ACCEPTED BYi' DATE �Q <br /> ADDITIONAL 4COMMENTS <br /> PHASE II' GROUT INSPECTION PHAS III/ INAL INSPECTI94 . <br /> INSPECTION BY DATE f0 - INSPECTION INSPECTION BY DATE <br /> E H 1426i ., 3/762h.. <br /> Rev. 1-74 <br />