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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFIC U E: 1.601 E. Hazelton Ave, , Stockton, Calif, <br /> n Telephone: (209) 466-6781 f <br /> APPLICATION FOR WEi CONSTRICTION OR PUMP PERMIT Permit No. 2 y 7 4c,) i <br /> � 78's6fa i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2- -Z7 i <br /> (Complete In Triplicate) <br /> Application is hereby made to <br /> 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/*,&@*WN t iCENSUS TRACT <br /> { <br /> Owner's Name Phone <br /> i <br /> Address City <br /> t <br /> Contractor's Name � s License Phvne�l�� 2fd <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 11DEEP N '/% RECONDITION / / DESTRUCTION /-7 - <br /> PUMP INST LATION PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK, j- SEWER LINES SQ e-PIT PRIVY , <br /> - ^ "--S•EWAGE-DISPOSAL;FIELDCES'SPOOL/SEEPAGE'PIT tOTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> a( Domestic/private Drilled Dia. of Well Casing <br /> —]� Domestic/public Driven-, Gauge of Casing + <br /> Irrigation Gravel Pack ; Depth of Grout Sealer F <br /> Cathodic Protection Rotary ,,t Type"of-Grout <br /> Disposal , Other Other Information <br /> Geophysical > '..Surface S,eai Installed By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump ✓ .%. -H.P. - <br /> 4 � y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP �,REPAIR: <br /> � T <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diamete '9 A_ pproxim_ate-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 /> information is true to the best of my knowle and belief, I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED LE <br /> NffMV PLITA PAAN ON REVERSE SIDE) j <br /> PHASE I FOR D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 7-114-77 <br /> ADDITIONAL COMMENTS: T� <br /> P S I GROIT INSPECTION PHA E /FIN INSPECTION <br /> INSPECTION BY ZC DATE Z fJ INSPECTION BY DATE <br /> 7 2 W~C.l� <br /> E H 1426 RPu�I_7 ' / f , 1177 '' 2M <br />