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C�s ar lb. `' SAN JOAQUIN LOCAL HEALTH DIST-RICT <br /> FOR OFFICE !USE: 1601 E. Hazelton Ave. , Stockton, -Calif. <br /> Telephone: (209) 466-6781 <br /> ! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7,;7-171--7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued -/ -7 <br /> (Complete In Triplicate) <br /> Applicationllis 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 Dcv� CENSUS TRACT <br /> Owner's Name f �� �y _ _ Phone <br /> Address tl a �F <br /> City <br /> Contractor's Name License # �� Phone ' %• 76,74 <br /> r i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION Z/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TOJNEAREST: ' SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS l� •i <br /> Industrial Cable Tool Dia. of Well Excavation <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 G,_ <br /> Type of Pump fn H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,$ESR: `/�/ <br /> - State Work Done L wr <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � µ <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the-best of nowledge�-an. belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG AND A FINAL I IO . <br /> ITLE / <br /> SIGNED <br /> IDE <br /> LAN 'ON LRSE S !. . .. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE r- <br /> ADDITIONAL: COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I WFINAL INSPECTION <br /> INSPECTION. BY DATE INSPECTION C DATE LZ/-f 7Z _ <br /> 3/76 2M Ca <br /> E H 141,6 Rev. -1-74 __ <br />