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u <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EF1011%" OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/S <br /> THIS-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t Date Issued /-7 /- 77 <br /> (Complete In Triplicate) - .1 '--`'�' <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:2186 and the Rules and Regulations of the San Joaquin Lo ca ealt District, <br /> JOB ADDRESS/LOCTION '�' rs-ac — <br /> . . %�'Z� .�� � � CENSUS �� <br /> TRACT_ <br /> Owner's Name 11 el ' <br /> Phone <br /> Address --- - <br /> - cityj7 ai-sc <br /> Contractor's Name. Lice # ��/ Phone z-� <br /> 3�;F <br /> TYPE OF WORK (Check); NE <br /> WELL= DEEPEN j J RECONDITION J / DESTRUCTION /-] <br /> PII2�T'' INSTLATION / J PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other-/ij -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATEDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION SPECIFICATI_OIJS \. <br /> _��Industrial " Cable Tool Dia, of Well Excavation / Q. <br /> stic/private. +.f� L"Drilled. _ <br /> omestic 'j Dia. of Well Casing <br /> jpublic ,�' _: Driven Gauge of Casing �� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Proteetionlr'_Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical <br /> Surface Seal Instatilled B <br /> PUriP INSTALLATION: Contractor <br /> TYpe!of Pump n - H.P. <br /> PUMP REPLACEMENT: / / State Work Done �r <br /> PUMP .REPAIR: / j State Work Done i <br /> ��S TRUCI I4N OF WELL:Well Diameter - <br /> Approximate Depth <br /> es cr-ibe-Ma-ter-ial-::aiid--Piocedur-6 <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 /> ifter.completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of 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 /> 'RIOR 1'0 'R U NG . D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ?BASE I b <br /> IPPLICATION ACCEPTED BY DATE <br /> 1DDITIONAL COMMENTS: <br /> PHASE II GROUT.sINS CTION PHASY III F NAL INSPECTION . <br /> [NSPECTION BY ;DATE INSPECTION BY DATE <br /> 4 ell <br /> J <br /> E H 1426 Rev. 1-74 ... � -7 7- ZOO 1"177 <br /> 3-27.78�ry/IG�— 1 p r s�+��5 1.-n o rip•:� <br />