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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FDR OFFICE USE: 40 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 <br /> 77 5--;4,,4 <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 Regulations of the San Joaquin Local Health District. <br /> ..3`X=493- LJ- � 02.5'-- tSo-2-k I <br /> JOB ADDRESS/LOCATION 1 ��� CENSUS TRACT <br /> rt <br /> ,E <br /> Owner's Name Phone <br /> Address <br /> � City I <br /> Contractor's Name r License4 _ hone3__Lf <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL / EPEN / ] RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /PUMP REPAIR '/ / PUMP REPLACEMENT /_7AL <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 S <br /> INTENDED USE TYPE OF- WELL CONSTRUCTION SPECIFICATIONS `•' <br /> Industrial Cable Tool Dia, of Well Excavation <br /> P7-'Dome s tic/private : Drilled Dia. of Well Casing <br /> ;Domestic/public Driven Gauge of Casing _ <br /> 'Irrigation Gravel Pack Depth of Grout Seal <br /> ,Cathodic Protection Rotary Type of Grout <br /> iDisposal Other Other Information,. <br /> .Geophysical Surface Seal Installed By: _ <br /> PUMP IN STALLATION: Contractor q <br /> Type of Pump ` H.P. - [ <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .:REPAIR: /7 State.Work Done x t <br />'r DE&TRU.CTION OF WELL: Well Diameter Approximate Depth <br /> k / Describe Material andNProcedure C <br /> I hereby agree to comply with all laws a hd-'xe.gulations of the San Joaquin Local Health District <br /> and the` State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> E <br /> after., of my work on 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' inu`s_e The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FORA-GROUT,'.INSPECTION <br /> PRIOR TO .GROUI-MRAND A FINAL CTION. �,,` <br /> SIGNED TITLE <br /> DR N. PLT PLAN "ON REVERSE SIDE <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE I -- <br /> APPLICATION ACCEPTED BY DATE f�� _ <br /> ADDITIONAL COMMENTS: <br /> PHAS jj GROUT INSPECTION PHASE.III/ INAL INSPECTION <br /> INSPECTION BY (� DATE INSPECTION BY - DATE �3=.1 -2 <br />� ' .. � 3/76 21I <br /> rR N 1A?A Rav_ 1-74 <br />