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�.,.. <br /> pit et ( r ,_, - <br /> 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--678 . <br /> I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue VC 2-8 1§79 <br /> (Complete In Triplicate) 1 <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 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION <br /> All! f t -e CENSUS TRACT <br /> i <br /> Owner's Name ldC Sf/=�:K-.z Phone -�(f <br /> Address - <br /> �i' City to 7 'or� <br /> Contractor's Name f 6 ez,-1 e go// License d Phone <br /> -�� <br /> TYPE OF WORK (Check) : NEW WELL /4�;- DEEPEN / / RECONDITION / / DESTRUCTION /-7 _ <br /> PUMP INSTALLATION / / 'UMP REPAIR /—/ —PUMP -REPLACEMENT / J <br /> Other / / — <br /> DISTANCE TO-NaREST: SEPTIC TANK SEWER LINES /" f PIT PRIVY <br /> SEWAGE DISPO5,QFIELD ;5 Pv—CESSPO L/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -YT;L <br /> Industrial Cable Tool Dia, of Well Excavation /.I i ` <br /> l�Domestic/private Drilled Dia. of Well Casing � gf�,, - <br /> Domestic/public Driven Gauge of Casing r T r <br /> Irrigation Gravel Pack Depth of Grout Seal -4'fJl <br /> Cathodic Protection 1� Rotary Type of Groute�j r W <br /> :. Disposal Other Other -Information <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor s <br /> Type of Pump H.P. <br /> PUMP'REPLACEMENT: / / State Work Done w <br /> PUMP -REPAIR: / / State Work Done <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 '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 thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION G <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY % DATF/r� - y j'` (! . ...� <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT NS ECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT / <br /> `F H i L 76 T? i_-». `` 0. 77 ins <br />