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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI Permit No. 77-/7L_e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-aµ—?7 r <br /> '' (Complete In Triplicate) <br /> Application is hereby made to the San 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 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION P�BA.rz� V/JE Aec� A CENSUS TRACT <br /> Owner's Name j4�7;F1/G E,• Rd d G Au_J -- Phone <br /> Address (� �U A1Jt . City <br /> Contractor's Name License #eW�aZ Phone 4f�/� <br /> 7 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION `j7/ PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other '/ <br /> 4 DISTANCE TO NEAREST: SEPTICtTANK � SEWER LINES PIT PRIVY i <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 <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> I€ 1 Drilled Dia. of Well Casing <br />� � Domestic/private g <br /> Domestic/public f Driven Gauge of Casing � 41 <br /> Irrigation 1 Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal Other Other Information ' <br />€ GeophysicalY Surface Seal Installed B : �/� <br /> lj <br /> E PUMP INSTALLATION: Contracto r�� <br /> Type hof Pump11 <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work DoneR <br /> 1 <br /> 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 anew 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 GROUTI AND A FIN SP CTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN''ON REVERSE SIDE) i <br /> r ti FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY /�✓ DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PRASE04 FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> a <br /> ' ' .. 3/76 ?M <br /> E H 1426 Rev. 1-74 <br />