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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FgF,IOFFICE USE: li lbdl E. Hazelton Ave. , Stockton, Calif. <br /> iM Telephone: =(209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION- OR PUMP PERMIT Permit No. 77 <br /> II <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'JSSUED Date Issued/ <br /> �� (Complete In Triplicate) . •7 U � -�-E� ' <br /> Application is hereby made to the -San Joaquin Local Health District for a- permit to construct <br /> and/or install the work]iherein described„ This application is made in compliance with San Joaquin , <br /> County Ord'inance`.No. 1862 -and the Rules and Regulations bf,`the San •Joaquin LocalHealth 'Distriet. <br /> JOB ADDRESS/LOCATIONA CENSUS TRACT ' <br />€ Owner's Name !M r►�oe / '�� <br /> i <br /> Address 1 City f <br /> 4- <br /> Contractor's NameN LicensAlS�3 Phor <br /> c.TYPE`:OF!W�ORKw(Cheek} .2n;t,Er WA`WALL <br /> i <br /> .=SDE•EI'EN��/�/ E-C-O�DIT°T$N�`/_�=�ESTRUCTTON�I�T'"""�'��"��_x_..�=...� <br /> PUMP INST L TION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE,-TO NEAREST: SEPTIC TANK SEWER LINES, PIT PRIVY ' <br /> i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .f PROPERTY LINE - PRIVATE DOMESTIC WEL?,- PUBLIC DOMESTIC WELL <br /> ,,.INTENDED USE- .�' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 6 <br /> Domestic/private Drilled Dia. of Well Casing , _ Jb `� A <br /> Domestic/public Driven Gauge of Casing %Y `� <br /> Irrigation � Depth .of Grout Sea] So <br /> 4 <br /> Cathodic Protection Rotary Type of Grout Gent ; <br /> Disposal Other Other Information <br /> Geophysical �C!C Surface Seal Installed B c �;i; <br /> �i <br /> PUMP INSTALLATION: Contractor `I k <br /> Type of Pump,. H.P. <br /> PUMP REPLACEMENT: % / State Work Done <br /> ! <br /> PUMP .REPAIR: % / State Work Done <br /> r DES-TRUCTION 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 /> 4 after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofthe 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 IGNED 0 NG AND AI�FINAL INSPECTION. TI <br /> DRAW Ph'�T PLAN 'ON REVERSE S IDE <br /> • <br /> Fff DEPART ; <br /> PHASE I � <br /> APPLICATION ACCEPTED"BYE DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE II /ZINAL INSPECTION <br /> INSPECTION BY !r DATE INSPECTION. BY ATE 7✓7 <br /> 3/76 2M <br /> E H 1426 Rev. 1-7.4 - �� <br />