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~ Old SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r- 0 rqq Telephone : (209) 466-6781 f <br /> APPLICATION- FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-3 9o4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toithe 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 CENSUS TRACT <br /> Owner's NamePhone a <br /> p t <br /> Address 1� City <br /> J <br /> Contractor's Name Ca License #A5/2S_-0-Phone <br /> L <br /> TYPE OF WORK (Check) : NEW WELL /;;7/t DEEPE % RECONDITION /_/ DESTRUCTION /-7` <br /> PUMP''fNSTALLAT IONS=W PUMj`REPAIR=}/�: <br /> -------Other /_�./ _ . <br /> DISTANCE TO NEAREST: SEPTIC TANK -q-7 ;, SEWER LINES q. PIT PRIVY <br /> SEWAGE_DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPEtiOF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial { Cable Tool Dia. of Well Excavation / <br /> 4--Domestic/private r. r ISril-led Dia. of Well Casing _ <br /> Domestic/public t.. Driven Gauge of Casing _ J�'C,- 16.p <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I t -Rotary - Type of Grout <br /> Disposal ': Other ! Other Information <br /> Geophysical. . Surface Seal Installed By: 0 <br /> r <br /> PIW INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> REPLACEMENT: /-7 State Work none , ,. <br /> PUMP .REPAIR: _ Q + <br /> / / State Work pone <br /> I vv✓r�� VIV <br /> DES TRUON"0_F''WEi�L:�..�.�Well Diameter- Approximate Depth <br /> a Descr be,Material anfProcedure <br /> I hereby agree to comp y withia 1— iws and regu a ions of t San Joaqu n Local Health District <br /> and the State­of_Cal-i-forni 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR. G ANR A FIN NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PWr PLAN 'ON REVERSE SID <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYj i PC DATE <br /> ADDITIONAL COMMENTS: t <br /> _­ <br /> PHASS74 GROW INSPECTI N P Sxj FIN PECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE f / <br /> ..)f et,146e, 'OV JV � 7 a <br /> E H 1426 Rev. 1-74 . . <br />