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SAN JOAQUIN LOCAL HEALTH. DISTRIC% l <br /> FOR OFFICE SE: t/ 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> !!!«< Telephone: (209) 466-6781 <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74-S.;[`p <br /> ` THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date Issued I <br /> (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <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 SZ- c G CENSUS TRACT <br /> Owner's Name �. � � / - /_rj 40.*, Phone <br /> Address �. j 0 City ®.4,'A17 AO e0 � <br /> j <br /> Contractor's Name o4,,, License # dty_%T­Phone <br /> TYPE- OF WORK (Check) : NEW WELL/ / DEEPEN /_/ 'RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP"REPAIR PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE-TO-NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> ---x Domestic/private Drilled Dia. of Well Casing Lr� , <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 w.e.c.. °' H.P. 3 <br /> PUMP REPLACEMENT: / / -State Work-"Done <br /> PUMP .REPAIR-. , „.f State�Work 'Done _ 2 <br /> DESTRUCTION OF WELL: Well Diameter ., "" Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lads and regulations of the San Joaquin Local Health District I <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 /> informatiot is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTNG ANDA FIN _ 0 f <br /> SIGNED TITLE _ <br /> DRA PLT PLAN''0 VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �p , <br /> APPLICATION ACCEPTED BY _ �7� f/� _ DATE 3'>.3-Zz . <br /> ADDITIONAL. COMMENTS: - <br /> PHASE II eROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATES <br /> E H 1426 3/,76 2M <br /> Rev. 1-74 � <br />