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f - <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNY PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 workfherein 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 /> I� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name rl Phone Z 33 76 7 <br /> l' , <br /> Address 7 Ugej - CityF)-, <br /> 4 � K <br /> Contractor's Name License #ZEE \03 Phone <br /> TYPE OF WORK (Check) : NEW WELL_-/ DEEPEN / I RECONDITION / / DESTRUCTION /? <br /> PUMP INSTALLATION-/ UMP REPAIR/ I PUMP REPLACEMENT, 1-7 <br /> r � Other `/ /i <br /> DISTANCE TO NEAREST: SEPTIC TANK. EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD � CESSPOOL/SEEFAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL%2--0 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL) CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 'Dia. of Well. Excavation ) <br /> Z--D_o_mes tic/private Drilled Dia;. of Well Casing �' <br /> 14 -Domestic/public Driven Gauge- of Casing oY <br /> Irrigation Gravel Pack Depthof Grout�Se' Se'-. p nt - <br /> Cathodic Protection ary `~ Type .of Grout �k �►./-fes. _ ens_-�� <br /> Disposal. Other Other Information _ �y� _T_ _r G <br /> Geophysical Surface Seal Installed B <br /> y' ./114 <br /> I , � <br />, .PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: _ <br /> / / State Work Done <br /> D'L till <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 60" <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 RILLERS REPORT of���the well and notify them before putting the .well in- use. The above i <br /> inform on ,is, true to t t knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO- UTING AND i(F NAL E . ' <br /> SI C TITLE F <br /> 1ML T PLAN ON REVERSE SIDE) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ' <br /> I <br /> APPLICATION ACCEPTED BY. --- - !-DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GRO T INSPECTIO PHASE /F.INAL INSPECTI N <br /> INSPECTION BY DATE )=¢ INSPECTION BY DATE r l 8 <br /> 3/76 2M . <br /> A E H 1426 Rev. <br />