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1004 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OPICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 a <br /> THIS PERMIT EXPIRES-.1 YEAR FROM DATE ISSUED Date Is ued �� <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .g 2"7! S'- /EeLA,� t-M ,d—j oh A60e+.r4 r.-AP tt3-- 33v 0-2 <br /> JOB ADDRESS/LOCATION gAp ySo all,lAfo�Pec h�s.yex PJB CENSUS TRACT <br /> Owner's Named✓ JO Phone <br /> Address 0 rJ p Cit <br /> Contractor's Name _ License # f7_hone ti2A <br /> • i <br /> _ r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/_ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /mac/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <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 h <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irr:igation 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 6 H.P. <br /> PUMP REPLACEMENT: / / 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 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 off. my now a ge and' elief. I WILL CALF FOR A GROUT INSPECTION <br /> PRIOR TO TING .AND A FINAL CTIO <br /> SIGNED TLE rsS� _ _ 11i <br /> RA T P ON REVERSE SIDE) ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY _ / / - - - - - - — ---- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /..!�? DATE ,r- <br /> E H 1426., Rev. 1--74 <br /> 1/7.7 _ 2M <br />