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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP?LICAZION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77— <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 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 7 °-�� CENSUS TRACT <br /> Owner's Name 'V, a Phone 7 U <br /> Address T City D <br /> Contractor's Name L�,cenvs�e�� -4..APhone <br /> `s <br /> TYPE OF WORK (Check) : NEW WELL/G/' DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 26 Af SEWER LINES �_ 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 \ZIndustrial Cable Tool Dia. of Well Excavation /3 I-o" <br /> /Domestic/private Drilled Dia. of Well Casing �p <br /> Domestic/public Driven Gauge of Casing (� <br /> Irrigation / Gravel Pack Depth of Grout Seal \ <br /> Cathodic Protection Rotary Type of Grout �PG <br /> Disposal Other Other Information <br /> Geophysical Surface Seal -Installed By: <br /> i � . <br /> PUMP INSTALLATION: Contractor lA <br /> +, Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State- Work Done _ <br /> PUMP .REPAIR: / / State Work Done <br /> DES•TRU_CTI_ON_ 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 'constructi.on. 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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR AOIGROUTING AND A FINAL INSPECTION. f <br /> SIGNED a TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> I PHASE I APPLICA ION ACCEPTEDA31Y DATE <br /> ADDITIONAL COMMENTS: ' <br /> P GROUT I P Z /FINAL INSPECTION <br /> INSPECTION BY �"� INSPECTION BY NIN DATE- <br /> NRst,� k_� 'vat <br /> 1f/7 2M <br /> E H 1426 Rev. 1-74 <br />