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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0170FFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209,) 466=6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,w <br /> 74 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 76 <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 Regulatione .of the San -Joaquin Local. Health District. � <br /> JOB ADDRESS/j6e&TW ,s / •f .� t� _ . CENSUS TRACT <br /> c, �c <br /> Owner's Name 0!11 Phone ' <br /> Address .,e, ! � �- City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK:•,(Check): NEW WELL /gr DEEPEN '/? RECONDITION %T DESTRUCTION X7t <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7 PUMP REPLACkHiNr /7 ` <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /&y 4- SEWER LINES /00 PIT PRIVY /LU d- <br /> SEWAGE DISPOSAL FIELD 6 �` CESSPOOL/SEEPAGE PIT / e)ek4-OTHER . 1 <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 ) / f \ i <br /> Domestic/private D-rilled Dia.. of Well Casin&1 <br /> Domestic/public Driven -�Gau e=of-+Cm <br /> Irrigation __ -,. TGrave ac 4 Depth of GxoutgSeal Aw <br /> Cathodic Protection ;Rotary Type of Grout <br /> Disposal - Other " Other Information t <br /> „- <br /> Geophysical — - Surface Seal installed Bk: .a ' <br /> a <br /> PUMP INSTALLATION: Contractor 3V .._ <br /> :. <br /> Type .of Pump.4 �-�_"'� ' � H:P.' <br /> r V.j <br /> f <br /> PUMP REPLACEMENT: • State Work Donees �� '; ,,; <br /> � i I <br /> PUMP :REPAIR: /-7 State Work Done <br /> DESTRUCTION OF WELL: f' /� i <br /> We11 Diameter Approximate .Depth <br /> Demr a Material and Procedure ' -t t <br /> I hereby agree to comply with all aws: and regulations of t~.he San Joaqu�; callHea t District <br /> and the State of California pertaining;to or regulating...ell-"eons-t�tion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will�rnish h San, Joagiiin Local Health District a <br /> WELL DRILLERS REPORT of :the well and nA1fyhem before p�tting*"the..well.'in.use-.-- The above k <br /> information is true to th'e_best of my. knowledge ai Ud belief. I WILL-CAT. A GROUT INSPECTION <br /> PRIOR TO GROUTING AND-' F'1NAL INSPECTION----/;;"',' <br /> SIGNED _ TLE <br /> { <br /> ---' <br /> (DI&W PLO _PJAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED "&a <br /> DATE <br /> ADDITIONAL COMMENTS:PHASE I �s C» PHASE M1 FINAL INSPECTION <br /> INSPECTION BY ATE '� . .;*INSPECTION BY, - DATE - ,-- t <br /> _: <br /> E H 1426 Rev. 1-74 )117< 9M <br />