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lao <br /> � / SAN JOAQUIN LOCAL HEALTH DISTRICT d O y- <br /> FOE OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z- &J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-s,1-77 <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 of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION l !t�/NSD� '� CENSUS TRACT <br /> Owner's Name - •9�sf'�'s orf/J/,.rialc m�TZc� �/ <br /> / I �7 Phone <br /> Address �(o 0� "�vLt �{J���. `207 City-.�1 <br /> Contractor's Name �QYV License Phone _�5117 <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL '/R DEEPEN/_/ RECONDITION / /- _"DESTRUCTION /7 <br /> PUMP INSTALLATION /g PUMP REPAIR / / PUMP REPLACEMENT /7 {; <br /> Other. <br /> DISTANCE TO NEAREST: SEPTIC TANK © SEWER LINES PIT'PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT *t OTHER <br /> PROPERTY LINEAdPRIVATE DOMESTIC WELL x1_ PUBLIC DOMESTIC WELL ' <br /> INTENDED USE 'TYPE OF WELL CONST'RUCTIONCSPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation. <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public [ Driven Gauge of Casing �Z <br /> Irrigation ! - Gravel Pack\j':, Depth of Grout Seal ��� � - h <br /> Cathodic Protection Rotar T <br /> Y Type of Grout � -1-e- rt-Ce,_,g.. <br /> Disposal ! Other Other Information ! <br /> Geophysical Surface Seal Installed By: --.lize,90t- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> � �.J1 <br /> PUMP .REPAIR: / /State Work Done . . F <br /> ;.,� <br /> DESTRUCTION OF WELL: Well Diameter c <br /> Approximate. Depth <br /> Describe Material and Procedure <br /> I � <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 on a new well, I will furnish the San Joaquin Local- Health District a <br /> WELL DRILLERS REPORT f the well and notify them before putting the well in use. The above # <br /> information is t to th st of y.knowledge and belief. I WILL CALL FOR A,GROUT INSPECTION <br /> PRIOR TO GROUT FINAL NS IO <br /> SIGNED Z TITLE <br /> DRAW PL OT PLAN 'ON REVERSE SID is <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I <br /> DATE � <br /> ADDITIONAL COMMENTS: <br /> PHASE I.I GROUT INSPECTION PHA I /,FINAL INSPECTION <br /> INSPECTION BY,/ff, -- DATE .2 ] INSPECTION BY DATE ",;P <br /> E H, 1426 Rev. 1-74 Y y 3/76 2M <br />