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F <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 'OFFICE USE: (/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issued 77- � <br /> 7TZ_ , jI (Complete In Triplicate) <br /> App ication islHereby-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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f JOB ADDRESS/LOCATION I�KrZ 77-Zff lea, � <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> _$ S- 7 6S,4 <br /> Address M f�� L/ f <br /> City JD cJ a L <br /> 'Contractor's Name OW A.f /Z-df � / /� �fQ , <br /> License .� Phon X��l. <br /> TYPE OF!WORK (Check): NEW WELL/rDEEpEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / --- 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD !'CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> 1 <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> _ Industrial l---Cable Tool Dia. of Well Excavation <br /> L�Ifomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 91 <br /> Disposal Other Other Information <br /> Geophysical �. "�'� � <br /> Surface Seal Installed BY.: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t - — H.P. <br /> F <br /> PUMP REPLACEMENT: F7 State Work Done i <br /> PUMP .REPAIR: / / State Work Done <br /> r <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 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 GR0PTING,,AND A FINAL INS ION. <br /> SIGNED TITLE <br /> D W'PL T PLAN ON RE FRSE SIDE / <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONS ; PHASErIII/_FINAL INSPECTION <br /> I ` <br /> INSPECTION BY �-= 7 7 DATE INSPECTION BY�%f ;/,6 DATE , r't 7 7 <br /> r <br /> E H 1426 Rev. 1-74 375 2M <br />