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r <br /> r- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �OfiOFFICE USE: i 1601 E. Hazelton Ave., Stockton, Calif. <br /> lTelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z6_3l 5"4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4r-11— <br /> 76 <br /> (Complete In Triplicate) <br /> t,pli.ecion ib her^by made to the San Joaquin Local Health District for a }ermit to construct <br /> and/or install the work herein described. This application is made in compliance with Sam Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ? 7 ,3 c/ C?dSUS TRACT <br /> Owner's Name Phone <br /> Address 2 73 2y <br /> Cit <br /> ,per i <br /> Contractor's Name /�.��. !7//�/��. � License 6 7/GG2 Phone <br /> TYPE OF WORK (Check): NEW WELL /T DEF?EN /% RECONDITION r7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT / <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> 1 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUALIC DO STIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS V <br /> Zndua trial 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State work Done <br /> PUMNP '.REPAIR: /7 State Work Done <br /> . DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -- <br /> Z 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 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 /> W-.LL DRILLERS REPORT o: 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 GROUTING <br /> SIGNET AND AAL AO,.�N. <br /> TITLE <br /> 2IOT NREVERSE <br /> SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��: f; _ - 'T <br /> •_ �'- DATE /-/o 'IG <br /> ADDITIONAL COHIgNTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY ' DATE i - _ ZNSPECTION BY ':. � DATE ="'.i" <br /> E H 1426 Rev. 1-74 6/75 2M <br />