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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 7 /3LE <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete .In Triplicate) <br /> Application is Aereby 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 y , S tS <br /> CENSUS TRACT <br /> owner's Name ,L� / Phone ' 3 - 2 <br /> Address'!-- Z. iZ' • Sf ZA_ City , 14 <br /> Contractor's Name f License # Phone <br /> f,:,TYPE-OF- WORK(Check); NEW-WELL DEEPEN /_/ RECONDITION 'DESTRUCTION <br /> DESTRUCTION <br /> AL <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK V4,01 SEWER LINES PIT PRIVY ---.� <br /> SEWAGE DISPOSALFIELD ­---- CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE'M PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> : INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ X Cable Tool Dia. of Well Excavation y '� <br /> Domestic/private. Drilled Dia. of Well Casing <br /> : Domestic/public Driven Gauge of CasingI Z 1 ,E ` <br /> Irrigation Gravel Pack Depth of GroutSeal <br /> Cathodic Protection Protection Rotary•`\ `. Type of Grout <br /> 'Disposal Other s ' Other Information -� <br /> Geophysical �' Surface Seal Installed By:_ <br /> PUMP INSTALLATION:-- Contractor <br /> Type of Pump ..� 'H.P, `l <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: Ll State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth . <br /> Describe Material and Procedure <br /> I hereby .agree to comply with all laws and regulati6ns of the 'San Joaquin Local Health 3strict <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> tafter' couipletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT d tLeegL1,Pnd , ot'fy them before putting'the..well in use. The above <br /> information i.s true t �Ethowled.ge-and belief. I WILL ,CALL FOR A GROUT INSPECTION <br /> 'PRIOR.T AN AF <br /> SIGNED ��. • ' ' TITLE ',1e <br /> DRAW PLOT ..PLAN ON REVERSE SID.E)_,_.. ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION <br /> BY <br /> - • <br /> ADDITIONAL COMMENTS: <br /> "PHASE- II dIGROUT- INSPECTION PHASE _JT�I/FINAL INSPECTIO ` y <br /> INSPECTION BY J1� DATE n/ INSPECTION BY DATE /Z / 7/ <br /> F ' <br /> 1777 _ 2M <br /> E H 1426 Rev. 1-74 <br />