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• r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: ' 1601 E. Hazelton Ave. , ;Stockton, Calif. 9 jl <br /> Telephone: (209) 466-67817-7-17,67- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedDEC 28 1971 <br /> ! (Complete In Triplicate) <br /> Application is 4ereby made to the San Joaquin Local Health District for a permit to construct' i <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 /> JOB ADDRESS/LOCATION' -t CENSUS TRACT <br /> :: _&j <br /> Owners Name hone <br /> l <br /> Address _jg City ' .. <br /> �29� /3 Phone S S <br /> Contractor's Name �4�5 A License # & <br /> aP .; <br /> (Check) : NEW WELL T DEEPEN /_/ RECONDITION / f DESTRUCTION_ /-7. <br /> TYPE OF'-WORK { ) � _ _ <br /> PUMP INSTALLATION / / PUMP .REPAIR:/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO'NEAREST:-F. SEPTIC TANK n.eh SEWER LINES PIT PRIVY - <br /> '� SEWAGE DISPOSAL FIELD t CESSPOOL/SEEPAGE 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 /> . Domestic/private Drilled Dia, of Well Casing 'f <br /> Domestic/public Driven Gauge of Casing J 41:63.e <br /> Irrigation j/ Gravel Pack Depth of Grout Seal # YE." <br /> Cathodic Protection L/ Rotary Type of Grout �* <br /> -Disposal Other Other Information 'j, nAJILLA <br /> - <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLA ION: Contractor __n <br /> Type of Pump f.. - H.P. <br /> PUMP REPLACEMENT: / /�.. State Work Done <br /> PUMP -.REPAIR: / / State Work Done _ IS.%` 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FI AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY I-/z-�8 Pte/ s✓ac/,, - 1A <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE�Z.� r' <br /> ADDITIONAL COMMENTS: <br /> PHASE II 0 C N PHASE II/FIiAL INSPECTION <br /> INSPECTION BY . DATE a- -77 INSPECTION BY DATE ,77-12-79. <br /> ro"I - ;�?q . 1/77 6�*.2m <br /> S/-e-c-r t `rSSflCr <br />