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,. SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> i . FOF OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- TeW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 <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 E �3 / 499 LELai> CENSUS TRACT <br /> Owner's Name Wa-skXR- �. Phone 3 �. <br /> Address lQLF- (� l� City S <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> i PUMP INST LLATION / / PUMP REPAIR/ / PUMP REPLACEMENT IJT <br /> Other <br /> 1 <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, {.s'+. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool' Dia. of Well Excavation <br /> l Domestic/private Drilled Dia. of Well Casing " C <br /> i Domestic/public Driven Gauge of Casing zz�Q <br /> Irrigation ; Gravel Pack Depth of Grout Seal <br /> Cathodic Protection , Rotary eAS l Type of Grout <br /> Disposal J J Other `� Other Information <br /> pGeophysicad. - ; � Surface Seal Installed By: <br /> � _ _ �'j ,_.., <br /> s PUMP INSTALLATION: Contractor <br /> Type ofl'Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> lDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 an a new well, I will furnish the San Joaquin Local Health District <br /> r 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 /> 1PRIOR TO GROUTING DA L SPECTION, <br /> 1, $ TITLE �n ilA ✓� -- <br /> SIGNED -- <br /> f .-_,___-_,(DRAW _PLOT. PLAN ON REVERSE SIDE)_-_ <br /> I FOR DEPARTMENT USE ONLY„ . , <br /> I, APPLICATION ACCEPTED BY �s^Na,.e DATE S' o " rI _ <br /> ADDITIONAL COMMENTS: 1. <br /> PHASE II GROUT INSPECTION LZ: PHASE II,I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -�•- <br /> : 1 f T7. 2M <br /> R R 1426 RPv- 1-74 <br />