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v SAN JOAQUIN LOCAL. HEALTH. DISTRICT <br /> :FOR OFFICE USE: 1/ x.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued :3•-/ '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 Rules d gulations o t e San Joaquin Local Health District. <br /> CENSUS TRACT_ <br /> JOB ADDRESS/LOC <br /> Ph one <br /> Owner's Nam <br /> a,.-'-.`—Ci y .. <br /> License 11Phone <br /> Contractor's Name <br /> _ <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN /�./_ RECONDITION / / DESTRUCTION jrT <br /> j <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE � PRIVATE DOMESTIC WELLCdNSTRUCTI C DOSTIC WELL <br /> SPECIFICATIONS C <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Rotary-,.-- ..T pe.of. Grout:- �. <br /> Cathodic Protection - '- -� <br /> twl— D sposal' Other Other Information <br /> Geophysical �� Surface. Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump 1 <br /> f <br /> � pip REPLACEMENT: . / f State Work Done <br /> PUMP-,REPAIR:.-- � State Work Do J- <br /> DESTRUCTION OP' WELL: We11 Diameter Approximate Depth <br /> Describe Material and rocedure <br /> I hefeby 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'constructiou. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true;�to the .bes_,t_off my�knowledge andi belief WYLL CAI:L—FOR'"A GROUT=INSPECTION= <br /> PRIOR TO GROUTINGaAND A FINAL INSPECTION. <br /> TITLE ° <br /> SIGNED <br /> DRAW-PL T PLAN.'ON RE 9R SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I M DATE <br /> APPLICATION ACCEP BY <br /> ADDITIONAL COMMENTS: { .• PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE -7? <br /> INSPECTION BY <br /> DATE i INSPECTION BY — <br /> f r 3/7 22M <br /> i E H 1426 Rev. '1-74 - <br />