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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FO-. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 �. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 6 <br /> i <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued ZLZO--77 <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 ules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS i �� � / � ` <br /> /LOCATION , fit/, �,Cy�,- 1�_j,� -CENSUS TRACT <br /> Owner's Name RPhone4/4 4 3 - �Cj - <br /> Address QCity <br /> Contractor's Name O'�J "16—C orLicense #&,;373 Phones <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION / / DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION W_PUMP REPAIR / / PUMP REPILACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ' 0 / SEWER LINES /q70 ♦ PIT PRM <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI—T ,,2_/ 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 /> Domestic/public Driven Gauge of Casing /2- <br /> Irrigation XGravel Pack- Depth of Grout Seal <br /> i Cathodic Protection- Rotary Type of Grout <br /> Disposal Fy Other Other Information _ <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION:. _ Contractork- 62-—.1- <br /> 's 0 <br /> Type of Pump H.P. ' / <br /> F <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: "` {�" <br /> /�/ "State Work Dane <br /> FDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - : - ----- Describe Material- and Procedure <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 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 est of my k �wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AGDA FI AL INSPEC <br /> SIGNED TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE1�"�C� <br /> ADDITIONAL COMMENTS: <br /> PHA E GRO INSPECTION PHA NAL INSPECTION <br /> INSPECTION BY DATE �i/ INSPECTION BY DATE <br /> r'Lv�7 <br /> E H ,.1426 Rev. • 1'V, ' <br /> 2M <br />