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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 �7��d�p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 71W <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 work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ' 81t,6, CENSUS TRACT 1 <br /> Owner's NameCA Phone <br /> Address City c!f}.GnIJ <br /> Contractor's Name License # Phone <br /> i <br /> a� <br /> TYPE OF WORK (Check) : NEW WELL f / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION Z/ 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 WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation W <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public-., Driven. Gauge of Casing .-- - <br /> Irrigation <br /> asing .Irrigation Gravel 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 Z74rx F <br /> Type of Pump 44d 2.2 i H.P. <br /> 7-• <br /> PUMP REPLACEMENT / / State Work Done <br /> f <br /> PUMP '.REPAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter (p�` ' Approximate Depth <br /> Describe Materialand Procedure <br /> P � e Fa�-�Aw �'.1+t(/� [.!��1��t ic�/i�F- est's_� =� �•r.�:. R <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 'construc.tion. 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 thfwell and notify them before putting the well in use. The above <br /> rinformati6n--Iis true torfty best of my knowledge and belief. I WIL CALL FOR A GROUT INSPECTION <br /> PRIOR :T G ING AND INAL INSPECTION. <br /> SIGNED TITLE <br /> zz (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE''I r �7 <br /> APPLICATION ACCEPTED BY �( DATE' <br />.ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S �II/FUNAL. INSPECTION <br />,INSPECTION BY DATE INSPECTIONBYDATE - - M3 <br /> -•. <br /> 1177 . 2M <br />