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GE <br /> f r SAN .TOAQUIN 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. 77 SSl� <br /> 77-s6s /"o <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4L_A1 <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 District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's,Name�: r tiC,C� .r* ► Phone_T4 F7 <br /> A <br /> Address ! City <br /> Contractor.'-.s. Name i.- _ �� License BPhpne_; <br /> _ �. <br /> i <br /> 1� <br /> TYPE OF WORK (Check) : NEW WELL/RDEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT, /. <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK ��j SEWER LINES PIT PRIVY © 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELiL- —\ P-UBLIC-DDMEB-TIC-WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION�SPECIFICATIONS <br /> Industrial _ Cable' Tool Dia. of We11 Excavation j X <br /> Domestic/private Drilled Dia; of'�Well -Casing,, , �'•• ,_ ____ <br /> R Domestic/public Driven - Gau erof_ Casi-n <br /> g_ $... --- a_ <br /> G Irrigation' Gravel Pack Depth of Grout "Seal"_ *�' "� i <br /> Cathodic Protection Rotary Type of-trout j . <br /> Disposalposal Other' _Other:Information `l S�-c <br /> 1 <br /> Geophysical - *Surf a6e' S-iAa: '`-Instal3ed'B�"" erJ <br /> r.. <br /> PUMP ,INSTALLATION; Contractor ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / StaWork Done 4 <br /> PUMP .REPAIR: / / State Work Done <br /> DES_ UCTION OF_ WELL: Well Diameter `' Approximate Depth <br /> - <br /> Describe Material and Procedure <br /> I hereby agree to comply th 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 them before puttingthe 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 GROUT G D IN I PE <br /> SIGNED y1, TITLE �� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C. 03% DATE $'V22) <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL 'INSPECTION <br /> INSPECTION BY DATE INSPECTION-_BY.ti . - ._,. . „ DATE <br /> _ - --- - 1 f�7 2M , <br /> E Hi_14.26. Rev. 1-74 _ _ .- . <br />