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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> • Telephone : (209) 466-67822 ��/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEFMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION /6 7 7 CENSUS TRACT r:,-s <br /> Owner's Name Phone 17 3 ^?3 [1 <br /> Address <-�� 7 '` �� �«- -1 't' City _W4 My . <br /> Contractor's Name 1"(, \r_7;r jmp �, �j���T\� License # Phone Ry l _CL <br /> TYPE OF WORK (Check) : NEW WELL`/DEEPEN / / RECONDITION /" / DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / '/ PUMP REPLACEMENT /-J <br /> Other <br /> t— <br /> DISTANCE TO NEAREST: SEPTIC TANK ' f SEWER IrINES`ZPIT-_PRIVY _ <br /> SEWAGE DISPOSAL FIELD .. CESSPOOL/SEE]PAGE .PIT OTHER <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 / <br /> 4----Domestic/private Drilled Dia. of Well Casing [ S <br /> Domestic/public Driven Gauge of Casing. <br /> Irrigation Gravelr,Pack�_, _ Depth of Grout Se -+ <br /> Cathodic Protection x---Rotary Type of Grout r, <br /> Disposal Other , Other Information �A4-6 , T P <br /> Geophysical Surface Seal Installed By: , � 5, <br /> PUMP INSTALLATION: . 'Contractor. efid, <br /> Type of Pump62> - H.P.. <br /> PUMP REPLACEMENT / /. State Work Done \' <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ;J__.— Approximate Depth <br /> Describe Material and Procedure , <br /> i 4 <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. "Th'e, above <br /> infor is true to the ofwledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND A FIN IN I �. <br /> SIGNED TITLE <br /> - D T -PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE-,ONLY <br /> PHASE Z - <br /> APPLICATION ACCEPTED BY DATE _1_1-,1) 7J1 <br /> ADDITIONAL COMMENTS: <br /> PHA �I,� GROUT INSPECTIO ur PHASE FINAL INSPECTION <br /> INSPECTION BYATE •b ^• .INSPECTION BY ATE -7 <br /> ..�1,70 IV <br /> dyx v_ ' r <br /> 3 fes^, w � ` ' 4/76 ,� <br />