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s" SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF 6FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ermit No. 77-3 ,p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued t/!L2-� <br /> ' (Complete In Triplicate) <br /> Application is hereby madeito 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 Joiquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOS ADDRESS/LOCATION � �� � - CENSUS TRACT <br /> Owner's Name �_ -r �� Phone � '~ <br /> jjL , <br /> Address / X31 YWI <br /> .- <br /> Contractor's Name / G//fes'--r i License #-P16(f Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /-7 DESTRUCTION 1-7 <br /> PUMP IINSTA LATION / / PUMP REPAIR./ / PUMP REPLACEMENT <br /> Other <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS \(* <br /> Industrial # Cable Tool Dia. of'Well Excavation �\ <br /> Domestic/private Drilled Dia. of,Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Cathodic PratecCionY`�:: Ro.tary__. .______ _-:...._Typ.e; of <br /> Disposal �I Other Other Information <br /> Geophysical (sem Surface .Seal Installed B . <br /> . PUMP INSTALLATION: Cont' .actor _ <br /> Type of Pump H.P. j:..' . <br /> PUMP REPLACEMENT: L71 State Work Done Xrw (f-e4 �+2� �- <br /> PUMP ,REPAIR: /% State Work Done <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 bistrict <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> Mafter 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 G UTING A1jD A FINAL INSPECTION. _ <br /> SIGNED TITLE -� <br /> tV (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,. <br /> APPLICATION ACCEPTED BY DATE - - <br /> ADDITIONAL COMMENTS: �t <br /> PHASE IIGROUTIINSPECTION PHAS I/FI INS ECTION <br /> INSPECTION BY—... DATE —INSPECT ION-BU � _DATE_ �7 <br /> r . 117.7 <br /> E H 1426 Rev. 1-74 - <br />