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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> FOF .Q FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ° <br /> - �.•� Telephone: (209) 466--6781 94 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7- <br /> 77- <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-.2 1F 7 4 <br /> (Complete In Triplicate) <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 ,Joaqui.n Local Health District. <br /> .TOB ADDRESS/LOCATIONCENSUS TRACT <br /> ' + <br /> _# - <br /> Owner's Name Phone1� 4 �` <br /> s , <br /> Address , City _Je 6 _ <br /> Contractor's Nameo 1011 • W _ 4/!�[��-� License #aRyfro-rhone '�5�Z 2,5� <br /> a <br /> TYPE OF WORK (Check) : NEW WELL /— DEEPEN / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_7 aQ <br /> Other <br /> DISTANCE' TO NEAREST: SEPTIC TANK ,S'1 ` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -- <br /> Industrial able Fool'""- Dia, of Well Excavation <br /> 'Domestic/private i Drilled Dia, of Well Casing a <br /> Domestic/public 1 Driven Gauge of Casing a <br /> Irrigation I Gravel Pack .--..Depth of Grout Seal <br /> Cathodic Protection A Rotary ' Type. of Grout a �' asx <br /> Disposal t Other; € -Other Information <br /> Geophysical Surface Seal Installe VB`": S. <br /> PUMP INSTALLATION: Contractor refs�x: <br /> Type-of Pump: # PF. <br /> w <br /> PUMP REPLACEMENT: / / State Work Done m = <br /> PUMP .REPAIR: / / State Work Done ""` <br /> - � 11 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> yI 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 bes-tNof my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO `GROUTI D A F L CT <br /> SIGNED TITLE <br /> t (DRAW PLOT -PLAN ON REVERSE SIDE)_--" <br /> !: FOR DEPARTMENT USE -ONLY <br /> PHASE I <br /> ,APPLICATION ACCEPTED BY .' DATE Z�7 <br /> .�),DDITIONAL COMMENTS: F <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ' 22 INSPECTION BY DATE i 7 <br /> H 2 �?!77M <br /> E 1.4 6 Rev. - l-74 1--74 <br />