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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -w-K. 'O'FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209)' 466-6781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7e�Ov <br /> ,.�... .�. .1.—THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ i97� <br /> Z0`FSO 5- �[r.�, FEY_ ,�� f (Complete In Triplicate) _ <br /> Application is Aereby made to the San Joaquin Local Health District for a permit toconstruct� <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 1STRACT <br /> f <br /> Owner's Name A! Phone <br /> Address i <br /> City <br /> Contractor's Namezz A ILE 0 li License Phone <br />:..TYRE.OF -WORK 4Check) ;- -NEW WELL DEEPEN "/ / -RECONDITION-RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION REPAIR /��__�,,� •,�-r <br /> Other 1/ / / PUMP REPLACEMENT /� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD CESSSPPO.O,/SEEPAGE PIT OTHER -1 <br /> PROPERTY LIN /PRIVATE DOMESTIC WEL16ZZ4 PUBLICDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial [ Cable Tool Dia, of Well Excavation <br /> Domestic Drilled <br /> /private Dia, of Well Casing 9 <br /> Domestic/public l Driven Gauge of Casing <br /> Irrigation f Gravel Pack Depth of Grout Seal � �' <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal t Other yp <br /> Other Information <br /> Geophysical Surface Seal Installed By: , <br /> PUMP INSTALLATIDN - 'T Contractor <br /> i' <br /> Type of Pump H.P. . . . . Ye <br /> i <br /> PUMP REPLACEMENT: / / State Work Done e , <br /> PUMP .REPAIR:. / / State Work Done i <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 Districtf'a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> informations true to the 4est f my k wledge and belief. I WILL CALL FOR A GROUT .INSPECTION_ <br /> PRIOR TO UTING A FI PEC ; <br /> SIGNED TITLE r <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r:VW <br /> APPLICATION4-ACCEPTED -BY' DATE y� <br /> ADDITIONAL COMMENTS: 7 <br /> "PHASE-'II GROUT,INSPECTION�- <br /> INSPECTION._BY_ - � �ry .s <br /> - PHASE ...I ' <br /> /FIN "'INSPECTION <br /> ,DATE. �, Ik ECTION_BY/,�2 .. DATE <br /> "T <br /> E H ~1426 Rev. 1-74 1/77 <br />