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SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1 <br /> FOR OFFI USE: V 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?6�7r_LY0 <br /> k <br /> J THIS PERMIT E7CitRES 1 YEAR FROM DATE ISSUED Date Issued Y_ao"76 � <br /> y (Complete In Triplicate) �t <br /> !I Application is hereby made to the San Joaquin Lo.11 NeA.lth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqula l <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' ) <br /> JOB ADDRESS/LOCATION oZ /q �Q 0 /1 CENFUS TRACE <br /> a <br /> f: <br /> a Owner's Name lu <br /> ��11 d _ Phone <br /> Address aL? .3 OJa /hi City j <br /> Contractor's Fame( s.s� � License I d -7 hone L-717 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR /7 PUMP REPLACEMENT /�!•T <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 3 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v•� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled - Dia. of Well Casing 1 <br /> — Domestic/public — Driven Gauge of Casing 1 <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 \ 'Y�t�..�al� —iT�-� • ^ <br /> ! Type of Pump C•� b . � ._ R.P. <br /> PUMP REPLACEMENT: /kl State Work Done4 • - 6 <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 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 mywle ge and-bplief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO T-NG AND A FINAL INSPECTION. <br /> SIGNED " LE <br /> RA ON REV SE SID ' �' � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n /� DATE <br /> APPLICATION ACCEPTED BY t ��.� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY DATE, ' <br /> 241 <br /> 9/76 2M <br /> E H 1426 Rev. 1-74 - <br />