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✓� SAN JOAQUIN LOCAL HEALTH. DISTRICT w <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. 763 6a ed <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 /oma 76 <br /> (Complete In Triplicate) �5--130-[9 .; <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 , �sid� <br /> z ' Al JA's CENSUS TRACT <br /> Owner's Name * , <br /> I" "o P 6-D e Phone � <br /> f <br /> Address FZELnLI e City <br /> Contractor's Name 1-i2RVb7 ' /a,// D f.1 1jA1'6 License #2970 � Phone <br /> f <br /> TYPE OF WORK (Check) : NEW WELL /vr-DEEPER, /—./ nRECONDITION /% ' DESTRUCTION /7 j <br /> PUMP INSTALLATION / / 'PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK'�7-p!tl SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELD ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.. of Well Excavation i> J <br /> Domestic Drilled Dia, of Well Casing �1 <br /> /private <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation t---Gravel Pack ,. k � Depth-of Grout.Seal i <br /> Cathodic ProtectionRotary Type of Grout j <br /> _Disposal Other Other Information <br /> Geophysical --.Surface Seal_Installed_B _ q - -._' _3_"�._� <br /> t <br /> P.Up INSTALLATION: Contractor i <br /> + - Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> C . <br /> PUMP-:REPAIR7t-- State Work Done .. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth_ <br /> Describe Material and ProcedureFla /V <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION , <br /> PRIOR TO GROUjqNG AND A FINAL PECTION. <br /> SIGNED -&ro TITLE <br /> D .PLOT PLAN ON REVERSE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> /54 A <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION11007 - , <br /> P SPe1TAJX.NkL, I SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - i <br /> E H 1426 Rev:. 1-74 , 3/76 2M <br />