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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7j-k Z <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued _-�.I- 77 <br /> (Complete In Triplicate) <br /> Application ie 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. 3.862 and the Rules and Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION /, Jr OB i'P� [_a�/�� .. __ ' CENSUS TRACT <br /> Owner's Name . ct Phone ,79'3 126 Z <br /> ' Address v =a City CA ell . <br /> Contractor's Name ;# s7 License Phone - <br /> 4_1 <br /> TYPE OF WORK (Check) NEW WELL /DEEPEN /? RECONDITIOi'�'� DESTRUCTION /� <br /> PUMP INSTALLATION '/ / ' .PUMP REPAIR -1-7—PUMP REPLACEMENT <br /> t OtherLi <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, - E --PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" ' PUBLIC DOMESTIC WELL <br /> INTENDED. USE :-i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial " " Cable Tool Dia. of Well Excavationlak <br /> �8omestic/private Drilled Dia. of Well Casing �> <br /> >. Domestic/public T= Driven Gauge of Casing /D <br /> __. <br /> Irrigation Gravel Pack- Depth of Grout Seal <br /> Cathodic Prvtection� ��otary Type of Grout w - - <br /> Disposal Y Other Other Information <br /> Geophysical . Surface Seal Insfalled BY: A 1 T­e.�.r_Ive <br /> PUMP; INSTALLATION:'. Contractor <br /> Type of Pump H.P. <br /> X <br /> s <br /> PUMP REPLACEMENT: / State Work Done 'X? <br /> PUMP REPAIR: / �.Stat6 Work Done- r = f <br /> IDE&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hem by,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 mywork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of-the well and notify therm before putting the.-well in-use.. . The above <br /> ; information is true to the-best>of- -my. knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> iPRIOR TO GROUTING ' A YINU INSP I <br /> SIGNED " TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A <br /> APPLICATION ACCEPTED BY DATE -1�''�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> .INSPECTION BY DATE INSPECTION BY DATE /7-- -77 <br /> E R 1426 :. : Rev. 1-74 ,.. 2M - - <br />