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SAN JOAQUIN LOCAL HEALTH DISTRICT G7✓r� -,1 G«. j j� <br /> FOF OpFICE`USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> s � <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No._7w 7�/JGI <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued R'31-77 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , JJ __ <br /> 3``I`� CENSUS TRACT <br /> Ar H <br /> Owner's Name <br /> Y' Phone <br /> Address ' City <br /> Contractor's Name !469 A a12 �'/ ��' Phone �4�5^ 1/91" <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <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 WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation f 'r <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> ---- <br /> Domestic/public Driven Gauge of Casing f V <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection _X _ Rotary Type of Grout <br /> Disposal Other Other Informationn5m 4 &cz , <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ew� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 Vocal 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 best of my knowledge and belief. I. WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AND A FNAL IN ION. <br /> SIGNED _ TITLE <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE D - Z ]� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAaE,;53r/FINAj. INSPECTION <br /> INSPECTION BY DATE 1 -� $- �7 INSPECTION BY DATE x1- <br /> c -,,/yT, 3 P 7� <br /> E H 1426 Rev: 1-74 � Z �'�^"" fb ,�+J t'� '.• '?( <br />