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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF "OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7 <br /> THIS; PERMIT EXPIRES I 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 <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andlithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> rnzsT .J 6ENSUS TRACT <br /> F!G S8..l� <br /> Owner's Name <br /> j Phone <br /> Address 2.5G 'City Z-0 <br /> Son oaqum <br /> Contractor <br /> ts Name (Division of San Joaquin Sulphur Co.) License Phone 4 _7� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/ /� DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 l <br /> PUMP INSTALLATION lfifr 'UMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIT PRIVY <br /> SEWAGEjDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE.OF WELL CONSTRUCTION SPECIFICATION'S <br /> Industrial ! Cable Tool Dia, of Well Excavation <br /> Domestic/private 1 Drilled Dia.rof Well,-Casing' <br /> Domestic/public t Driven G'-auge of Casing f <br /> Irrigation € Gravel Pack Depth of. Grout Seal' <br /> Cathodic Protection 1 Rotary Type of Grout <br /> l <br /> Di posal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor kt-�. +�Y t t�:-�! _ U-^4 <br /> H.P. <br /> Type of Pump i <br /> _ r <br /> I PUMP REPLACEMENT: / / tate Work Done <br /> C PUMP REPAIR: M„ _/ / State Work.-Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply faith all. Jaws and regulations of the San Joaquin Local Health District <br /> and the State of California $ertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work ,an a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the sell and notify them before putting thewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FO A G0 T INS ECTION <br /> PRIOR TO GR D A FINA INSPECTION. <br /> {Division of San Jobquin Sulphur Co,) <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 4 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 'i f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �_ PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE F� ;,_ INSPECTION BY _- - DATE P -,77 <br /> 2M <br /> ' R N 1L9A RRv- . 1-74 ' _- <br />