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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> 70—FI-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 �3 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/0 ��"�' <br /> (Complete In Triplicate) k1W purer' # 77-2o 3W <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 /> Cou;Vy t _ance No. 1862 and the Rules and egul tions of the San Joaquin Local Health District. <br /> �/� / �/�/1) S 1h�JO RESS/LOCATION lt.t 112- ���R,�{ �,�,�� ,�1� TRACT <br /> Owner's Name .10 2 �NA 12C-A0SS-9 zr2 _-- -__-- - — Phone tf _ Y54/C2, <br /> Address /at, / 4-1 City sja�{i <br /> Contractor's Name ��, , f ��,� /dC, � ��C 4 .,.t License #;?U-761 Phone <br /> Y <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /)�J <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /jT -p" PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE30'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/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 <br /> -Disposal Other Other Information, <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor irrt2s / r-c . <br /> �y <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �`1 Approximate Depth <br /> Describe Material and Procedure i / f X, z-.e-,t - 2-�-- <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /© <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /Z "_7_� <br /> E H 1426 Rev. - I-74 -<--- - - - <br />