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r� 7"SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif._ <br /> Telephone : (209) 466-678111. 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT Permit No. 77-�3•s"f� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued E5;7-7' <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 R les and egulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT ✓ CENSUS TRACT <br /> /1� s <br /> Owner's Name P e , <br /> Address <br /> Contractor's Name VLicense/4'r)"323 Phon6'"`''! <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION I / PUMP REPAIR / f>rUUMP REPLACEMENT /-7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK •, SEWER .LINES PIT.,PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -PROPERTY LINE. :. PRIVATE.DOMESTIC WELL PUBLIC DOMESTIC WELL ( ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �, Cable Tool Dia. of Well- Excavation W . <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public.. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <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 /> PUMP REPLACEMENT: / / State *Work Done" ' <br /> PUMP :REPAIR: -tate-Work <br /> DESTRUCTION OF WELL: Well Diameter 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 California 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 the well and notify thein before putting the well in use. The above <br /> information is true to the best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �.r TITLE �r t�, :a <br /> !'IKDRAW. POT PLAN ON REVERSE SIDE) t, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A 7/"j-,-2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE.III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY t DATE 6-/r -2 7 <br /> . , t - I I I 1 .. 3/7 ; <br /> _,E Hy 1426 Rev. 1--74 ---- -- <br />