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SAN JOAQUIN LOCAL HEALTH DISTR?CT ` <br />� GOF. _OFFT.CE USE: 5601 E. Hazelton Ave. , Stockton, Calif. of <br /> Telephone: (209) 466-6781 7 7 F� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��//07 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Iasued S X-77 <br /> QG, (Complete In Triplicate) <br /> on <br /> Applicatiis hL by made to the San Joaquin Local Health District for a permit to construct <br /> and/or install t'he 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/LOCATIONA //OS IjW .6ArCd6_r4j _ _ CENSUS TRACT <br /> Owner's Name jC� ,J� �r a1 /,��rf 5 O/\/ Phone <br /> Address )( //D S / Lv /-/9 re,4 r4 _ city � <br /> Contractor's NameX ��.�Q( ,�,�,,,,.„ License I=X.9Z'�i�hone '5'47 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION! /7 DESTRUCTION <br /> PUMP INSTALLATION /�/ PUMP REPAIR / / PUMP REPLACEME T /7 <br /> Other IN � �S. j^�e«f cgt ----\ <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 <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 a <br /> Disposal Other Other Information <br /> Geophysical Surface Seal installed By 'p <br /> PUMP INSTALLATION: Contractor r S ail <br /> x Type of Pump --- H.P. -- <br /> PUMP REPLACEMENT: j_/ State Work Done — <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: ;K Well Diameter L __ Approximate Depth / 3b <br /> Describe Material and P ocedur <br /> istrict <br /> I hereby agree to comply with a laws and regulations o the`Sar. Joaqu n Local Health Joaquin <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. Tho above <br /> information- s true to the >Ist of my knowledge and belief. I WILL. CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND F INSPECTION. <br /> SIGNED TITLE <br /> DRAfJ PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONL <br /> APPLICATION ACCEPTED BY _ —� L .�� DATES 7 <br /> PHASE I <br /> ADDITIONAL COMMENTS: r ze /E „f. _ <br /> PHASE II �GR� OUT' INSPEC. N PHASE III FI AL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY �/DATE� _� <br /> r e!77 2H <br /> E H 1426 Rev. . 1-74 <br />