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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Teldphone: (209) 466-6781 <br /> APPLICATION FOR WE&L CONSTRUCTION OR PUMP PERMIT Permit No.7 7--1/70 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) -� 7 <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 /> II <br /> JOB ADDRESS_ ® CENSUS TRACT <br /> Owner's Name ! /7�� /a ���' Phone <br /> Address ,` 4,m� zoCity <br /> Contractor's Name J LicenseWA�zPhone�5r/��/0 <br /> II ` <br /> TYPE OF/WORK (Check) : NEW WELL / DEEPEN %/ RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /—T <br /> Other — <br /> � <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES - _(-PI PRIVY <br /> i SEWAGE DISPO!S6 FIELD CESSPOOL/SEEPAGE PIT I OTHER <br /> PROPERTY LINp'RIVATE DOMESTIC WELL ��® PUBLIC DOMESTIC`WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _X Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ` / <br /> IrrigationGravel 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 <br /> Type of Pump II H.P. a <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP .REPAIR: / / State Work Donee- -- 4 -- -r - -- - - - --- _� <br /> F V g � <br /> w. <br /> DESTRUCTION OF WELL: Well Diameter; `{7 ": E ,�. Approximate Depth <br /> Describe Material and-Procedure `e <br /> I hereby agree to comply with,all lawsl, and 'regulations of the San Joaquin Local Health District <br /> and the State of California pertaining! to or r6gulati'ng 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-DRIL-LERS -REPORT -of-the-we11-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. <br /> SIGNED l E *( <br /> (D PLOT PLq ON REVERSE SIDE) j <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEP'T'ED BY li DATE <br /> ADDITIONAL COMMENTS: <br /> HAS_ II GROUT INSPECTION11 S I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �'I8 <br /> ii <br /> E H 1426 Rev. 1-74 1/77 2 <br />