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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> [ FOE.OFFI E LTS'E: 1601 'E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) ,466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 777--(f 6d <br /> L' 50- wl�e cl T7 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued <br /> Y `.rw -'J <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 _. v,/V CENSUS TRACT <br />` Owner's Name zz -7 <br /> Phone `s dy. fl <br /> 4 Address City"ELAZ/7 <br /> Contractor's Name ell License Phone �z <br /> I <br /> TYPE OF WORK_(Check) :..,,.NEW WELL„/�J�" DEEPEN � RECONDITION /-7 DESTRUCTION—/7' <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /-7 <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 SPECIFICATIONS <br /> � �ndustrial 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 <br /> Type of Pump , <br /> H.Z. Q. <br /> PUMP REPLACEMENT: /State Work Done Y �i <br /> PUMP •.REPAIR: / / State Work Done <br /> I <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 notifythem before <br /> putting the well in use. The above . <br /> information is true to the-best.of my_.knowledge and belief. 1 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING Aap--A-FIN4 I SPECTION. <br /> SIGNED ` -� TITLE _ <br /> di <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' ' <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PECTION - PHASE III/FINAL INSPECTION . i <br /> INSP;ECTION BY::__ . DATE INSPECTION BY ,� _ DATE <br /> E.•H1�+26 <:.;Rev.. 1-74 .. <br /> 177. _ 2M I <br />