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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR' OFFICE USE: ^ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 Sa g,41) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �ll�77 <br /> (Complete In Triplicate) <br /> Application is hereby made to C the San Joa uin Local, Health District for a permit to construct <br /> and/or install the work her �,R <br /> scribed. This ap tion is made in compliance with San Joaquin <br /> Coun y Ordinan a No. 1862 nd #t1 s nd gul do o the San Joaquin Local Health District. <br /> , .. � �� <br /> JOB ADDRESS/LOCATION i,4 f <br /> f CENSUS TRACT . <br /> Owner's Name 4�ZANJ< -klZ�DES Phone <br /> Address le <br /> City � <br /> Contractor's Name License #,A�Q� Phone <br /> jan t <br /> _ - 1 <br /> TYPE OF WORK (Check} : NEW WELL/ DEEPEN / / RECONDITION /-7 DESTRUCTION /? oQ <br /> PUMP INSTALLATION J PUMP REPAIR / / PUMP REPLACEMENT <br /> Other J J <br /> co � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ZLIO - PIT PRIVY <br /> SEWAGE DISPOSALjFIELD �d ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY .LIN PRIVATE DOMESTIC WELL ,M PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> I,— Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing lill-10 uj <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout -j�nI` _ t <br /> Disposal Other Other Information "� t <br /> Geophysical Surface Seal Installed BY: j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> k <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP .REPATR: tate Work Done <br />)ES•TRUCTION OF WELL; rW7-el' Diameter A 7roximate Depth + <br /> es rite ate ial a Procedure pp p <br /> I hereby agree to comply wit. all law`' and regulati ns of +the an Joaquin oral Health District f <br /> and the State of CaliYbisia`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 i <br /> information is true to the best of. my knowledge and belief. I WILL CALL FOIL A GROUT INSPECTION a <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> 5IGNED ITLE�- <br /> (DR.AW PLOT PL REVERSE SID <br /> PHASE I OR DEPARTMENT USE ONLY — <br /> kPPLICATION ACCEPTED B . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION J (, PHASE-III UNAL INSPECTION <br /> CNSP CTION <br /> BY j� DATE INSPECTION BY DATE <br /> E ,H 1426 Rev. 1-74 0-h U. iib Crit .®3- IIR 2M <br />