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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77�-�� + <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued —Zl- <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 herein1described. 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 rj v ,. CENSUS TRACT <br /> Owner's Name rZ.P/ , �. Phonelei-7,3 <br /> E. <br /> Address ! d RT City <br /> i <br /> Contractor's Name License ���i� /a_rS``�hone 634-��j <br /> r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/__/ RECONDITION V/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT F7 <br /> Other / f/ <br /> j „> <br /> DISTANCE TO NEAREST: SEPTIC TANK 04r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD } •40f/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 /> Domestic/private I— Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing _ /6 c q <br />'. Irrigation I Gravel Pack Depth of Grout Seal S� <br /> Cathodic Protection -11-. Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP .REPAIR:.- - - / / State Work Done �- �. �- ,.- .. -. *,►- --- . . ---- ._ . <br />)ES:TRUCTION OF'WELL:-' Well Diameter Approximate Depth , <br /> Describe Material and Procedure <br />[ hereby agree to comply with al-1 laws and regulations of the San Joaquin Local Health District <br /> Ind 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 /> 4EL'L DRILLERS REPORT of the well and notify them before putting the- well in use.. The above <br /> Cnformation is true to the best' of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED (y TITLE 6 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 j <br /> i <br />?HASE I FOR DEPARTMENT USE ONLY <br /> z <br /> APPLICATION ACCEPTED BY , DATE � Z � <br /> ADDITIONAL COMMENTS: <br /> I PHAS I GRO T INSTECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 7/ INSPECTION BY DATE - - <br /> 4 ! ' /z ' 1177 I +/ <br /> E.A 1426 Rav_ 1-7 : <br />