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ILO SAN JOAQUIN LOCAL.`HEALTH DISTRICT r nW6 <br /> EOPtOFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N 77- � !� <br /> 3 THIS. PERMIT EXPIRES 1, YEAR FROM DATE ISSUED Date I sued <br /> ` (Complete In Triplicate) <br /> Application is 'heireby made to: Che Sari 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 Joaquin <br /> County Ordinance No. :1862 and'Ithe Ru es and Re lations of the San Joaquin Local Health District. <br /> - f33�0 � aurs vE �. i <br /> JOB ADDRESS/LOCATION Call CENSUS TRACT <br /> Owner's Name i Phone $ <br /> Address ` ] City <br /> Contractor's Name 4� _]x4 /ice... Phone 9, Kl <br /> .�, r <br /> Other <br /> TYPE OF WORK (Check) : NEW.WELL_ DEEPEN/. / ` . O.NP TION,1_7 ..DESTRUCTION.. 7 _ --�-- <br /> PUMP IN LAION / / P REPAIR / / PUMP REPLACEMENT /� <br /> / / ..•� `" r <br /> A <br /> DISTANCE TO NEAREST: SEPTIC- TANK _z � R LINES /ap` ,;PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL __r—PUBLIC;DOMESTIC WELL -r ' <br /> INTENDED USE TYPE OF WELL, .- { CONSTRUCTION SPECIFICATIONS <br /> 'Industrial <br /> Cable Tool ' Dia. of Well Excavation <br /> Domestic/private _ _ 3. Drilled_ - Dia. of Well Casing 41 <br /> ' <br /> Domestic/public E. Driven ' Gaugeof Casing <br /> Irrigation } '`"i ` Gravel Pack Depth o� fGrout=Seal <br /> Cathodic Protection Rotary Type of Grouter . . <br /> Disposal { Other �" Other Information~ _. <br /> Geophysical SurfaceSeal- -Installed By:' - ---. ' <br /> -� - - _i . . .. t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .. H.P. ` " <br /> PUMP REPLACEMENT: ` ! /, / ,y.State iW6rk Done <br /> PUMP :REPAIR; a t , ,/3 /`} State Work Done <br /> , <br /> ESTRUCTION 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 /> informatio is true. to thest of m77 �x�owledge and belief. I WILL CALL FOR A GROUT °INSPECTION a)m, <br /> PRIOR j2::Gj!tTjPG AP AFIW SPFM <br /> SIGNED' TITLE ► <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DE TMENT VSEONLY <br /> PHASE I _ I <br /> APPLICATION ACCEPTED BY DATE -/? <br /> ADDITIONAL COMMENTS: <br /> PHASE II: GROUT INSPECTION PHASE III/FINAL INSPECTION. ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1177 <br />