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m. SAN JOAQUIN LOCAL. HEALTH DISTRICT S 1 y Y717 T q <br /> FOE.OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (-209) 466-6781 j V 3/7� � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77 7/3�1r) <br /> r <br /> THIS PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued 7 � <br /> (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 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 Di.str�ct. <br /> JOB ADDRESS/LOCATION . CENSUS TRACT • <br /> Owner's Name Phone 3rc i -s a <br /> Address City <br /> Contractor's Name /&g<- License # � ./ Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DJSTANCE TO NEAREST: SEPTIC TANK SEWER LINES <;0 i PIT PRIVY .y <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT — OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLS .+ PUBLIC DOMESTIC WELL <br /> iNTENDED USE TYPE OF WELL v CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " (� <br /> Domestic - - ---- 1 <br /> /private_ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge -of Casing1p <br /> ' <br /> Irrigation Gravel Pack Depth of Grout Seal Vj <br /> _ -_ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other 'Information ---- <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor --- , <br /> Type of Pump H.P. <br /> �* <br /> i <br /> � { z <br /> PUMP REPLACEMENT: ,' / /. State Work. Done w <br /> UMP •REPAIR: .. . - - .• .4 ,� <br /> StateWork-Done- <br /> DES- RUCTION OF WELL: Well Diameter <br /> . Approximate Depth <br /> Describe Material and.Procedure <br /> I hereby agree to comply with alllaws and regulations of ,the San Joaquin Local Health District <br /> and'the State of California pertaining to or regulating well 'construct"ion. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and not)efy them before putting the .well in use. The above <br /> information is--true. o-.-thee&- - b-elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T NG A FIN P <br /> SIGNED 5' TITLE 4aAwz , <br /> QLK&W PLOT FLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BY DATE - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT- INSPECTIOE P E JJUFINALINSPECTION <br /> INSPECTION„BY. _ __,._. DATE INSPECTION BY DATE - <br /> E .&: 1426 uP.,_ 1-7G 1/77cp2M <br />