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' " SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOP. OFFICE USE 1601 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7; - 203it" <br /> 77-� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-7-77 <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 5a Joa in Local Health District. <br /> /Vo 1.12 <br /> /90 S3 ''Y �! �• F,-v�ff���{ s s«'c <br /> JOB ADDRESS LOCATION r SUS TRACT <br /> I i. - U <br /> Owner's Name ?_Q �A p",ar,S �t Phane ��•� �`ey <br /> Address �C1 G?i t _ City' 7`ael�Tc <br /> Contractor's Name License # Phone C'3 <br /> i <br /> TYPE.OF WORK (Check) : NEW WELL /c ;F-' :DEEPEN /. / RECONDITION /_� DESTRUCTION /-7 _ <br /> PUMP INSTALLATION /dam PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDf. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �te Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing LL q W ^ <br /> Irrigation Gravel Pack Depth of Grout Seal J-0 <br /> Cathodic Protection s.--* Rotary 'Type of Grout ��c�ns'�-�e,c,•f TeQ- _, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By b.yibeiryC++C Oer,M_/J y <br /> PUMP INSTALLATION: Contractor Ly j we fl 5"*X a A, f'v _ 1- r*-c <br /> _ Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done' <br /> PUMP .REPAIR: / / State Work Done <br /> wu v�� w ll <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 GROUTING AND A FI AL INSPECTION. <br /> SIGNED jTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY /L-?-79 rim <br /> PHASE I _ <br /> V1141;1' 1 <br /> APPLICATION .ACCEPTED BY DATE j? „,.. 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY /yj DATE D-Z6-- -7 TNSPFCTION BY DATE /Z-7-77' <br /> ��� „C� <br /> E H 1426 Rev. 1-74 <br />