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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELLNCONSTRUCTION OR PUMP PERMIT Permit No. 7 7--,�iS W . <br /> .77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> �eeRA opee S�tcI&SeJOB ADDRESS/LOCATION } <br /> Owner's Name W4, 1 L s'5 -14Phone <br />' Address toY City <br /> i <br /> k Contractor's Name ti $ sys License # Phone _,&__.? <br /> i <br /> y <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / RECONDITION /� DESTRUCTION /� <br /> PUMP INST�ATION - PUMP REPAIR / / PUMP REPLACEMENT f� <br /> r <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />' SEWAGE DISPOSAL ELD "�,1_, CESSPOOL%SEEPAGE FIT dj .-OTHER <br /> PROPERTY LINE- ,IVATE DOMESTIC WEL151_2 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q• <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private � Drilled Dia. of Well Casing <br /> �{ Domestic/public Driven Gauge of CasingO <br /> �.. <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: 707K <br /> PUMP INSTALLATION: Contractor O 4 Ddb 5 � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT Y / / State Work Done *! <br /> ' <br /> PUMP :REPAIR: } / •:- <br /> State Work Doney / <br /> i <br /> DESTRUCTION OF WELL:{"'-Well Diameter Approximate Depth <br /> ;Describe Material and Procedure ' <br /> A� <br /> I hereby agree to-coo iT_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 <br /> WELL DRILLERS REPORT of the well and notify them 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, i <br /> SIGNED ITLE <br /> i n p L REVERSE SIDE) <br /> I <br /> FOR DEP TMENT USE ONLX 1 : ! <br /> � 1 <br /> i APPLICATION ACCEPTED B DATE Ea <br /> ADDITIONAL COMMENTS: T <br /> C PRASE _II ,GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BX DATE �17-7 INSPECTION BY DATE <br /> • I <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />