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C6 /o d�_SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFF CE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone': (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-,i1,5­ZP0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 _A <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / r` p dad rv��ct� ' 4,ci"�r_�eS.CENSUS TRACT <br /> Owner's NamePhone <br /> r <br /> Address <br /> City <br /> Contractor's Name License # 37X4 Phone y� <br /> TYPE OF WORK (Check) : NEW WELL %/ DEEPEN '/`'/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR' j_td PUMP REPLACEMENT /_ <br /> Other <br /> E 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 <br /> -- - Domestic/private Drilled Dia. of Well Casing <br /> - <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 1 <br /> _ -- -- <br /> PUMP INSTALLATION: , ContractorpiG , <br /> Type of Pump' ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done 4 /t .00L_ <br /> DESTRUCTION OF WELL: Well Diameter _ :'`:', j: - Approximate Depth <br /> Describe Material and Procedure ,n ' <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 t7e11 ''eons.truction. 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 putting. the 'well in use The above <br /> information is true to the best of my knowledge and belief. I .kLL CALL.FOR A;:GRQUT INSPECTION <br /> ' PRIOR TO _ - - <br /> TING AND A FINAL INS.P I N. <br /> SIGNED 1 .; . `' TITLE ,�le,5 <br /> ( KA 'PLAN ON ,REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> k APPLICATION ACCEPTED BY DATE -Z2-77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC PMS /FI INSPEC I N. <br /> INSPECTION BY DATE Z INSPECTION B DATE r• <br /> 1�.?7 <br /> E H 1426 Rev. 1-74 ' . _ _ 2M <br />