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Ie. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR .0 FICE USE:- �" 1601 E. Hazelton Ave,. ,' Stockton,_ Calif.--, <br /> •R <br /> Telephone: (209) 46616781 <br /> r, Y APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3/LrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued•/��3t�76 <br /> k - (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or installthe 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 /> iI F <br /> JOB ADDRESS/LOCATION j -lQ ` CENSUS TRACT <br /> Owner's Name Phone <br /> +f I <br /> Address /�(�5� City <br /> E � <br /> Contractor's Name G License # „2gaM Phone j22-1&431 <br /> i• <br /> aqr' .tr. :+ 1""•�, :: . .� rte.- _ �- - -- ^"� ,"-`:�•.�......r <br /> TYPE OF WORK (Check) : NEW WELL/! DEEPEN-'/—/ RECONDITION_/ / DESTRUCTION /; <br /> PUMP, INSTALLATION '/ / PUMP REPAIR '% / PUMP REPLACEMENT <br /> Other <br /> DISTANCE ;TO NEAREST: SEPTIC .TANK SEWER LINES r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �) ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE. DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED�USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS '1e <br /> Industrial Cable Tool Dia. of Well Excalation <br /> Domestic%private Drilled' Dia. of, Well Casing <br /> d�omestic/public �� :^ Driven• Gauge of Casing ! ._ <br /> rrigation . - r. :,, _ —.Greve -^L IQ �:tis- i % -- --- <br />` •"''�"`v"c`athodic Profe�, Rotary Type of Grout __ i�r7 "7`7/�Y,[-C J-- -•-- . <br /> Disposal 's Other Other information ' phi r <br /> Geophysical. Surface Seal Installed B i <br /> PUMP INSTALLATION:• Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:' . / / State Work Done <br /> PUMP .REPAIR• � / / State Work Done <br /> a .i p . • f <br /> DESTRUCTION OF.WELL: Well Diameter Approximate Depth <br /> I 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, 1 will furnish the San Joaquin Local Health Df§tx.i . 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 my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING .ANDA NAL IN ECT'ION. TITLE �. <br /> SIGNED , <br /> y s 77 <br /> D W i.OT ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY ', DATE�; S <br /> ADDITIONAL COMMENTS <br /> P II 1tO T INSPECTZ N s PHASE III IN IN ; <br /> INSPE TION BY ' DATE INSPECTION BY DATE `r <br /> 4 l G�'Gcl� _ . . <br /> r,} 3/76 2M <br /> IF E H-1426S� <br />�,, k Rev. 1; <br />