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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FOE OFFICE USE: I Cvd 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> mit No. 7 7' s�lG✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued x-31„ 7 <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 /> F County Ordinance No. 1862 and the LR,11!es and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION9/ ,tai O� �GJ <br /> Owner's Name <br /> Phone - 7��7� <br /> Address City <br /> Contractor's Name.I' tu'.11- Gt�oZ�1� /LL/�/ license /' hone �- 12 Z <br /> TYPE OF WORK (Check) : 'NEW WELL .�� -,-,—DEEP-EN�/ / : RE"CONDITION__/_�._DESTRUCTION f - <br /> kPUMP INSTALLATION / / PiJMP REPAIR / / PUMP REPLACEMENT IT <br /> _ „Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK to-o SEWER LINES IOU 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 UN_ <br /> Domestic/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 /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed BY: C � <br /> L i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P: � <br /> PUMP REPLACEMENT: /_7 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 Local Health'District <br /> and the- State of California pertaining to­oir regulating-well'construction. Within FIFTEEN DAYS <br /> after. completion of my work on a new well, I will furh.ish. the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we-1.1 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 GRO IN ANDA FIN SPECTION. <br /> SIGNED TITLE : " <br /> DRAW- PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -7 <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> �.. . _,... ..PHASE° 111./FINAL. .IN.SP.ECT.ION._ <br /> . -- - --- "PHASE II GROUT--�N�SPECTION� -'-.-._.�,.._�.,,,� t-- .. �. <br /> INSPECTION BY DATE INSPECTION BY• I}ATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />