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4 <br /> _ SAN JOAQUIN LOCAL HEALTH.DISTRICT .' <br /> FOF_ OFFICE USA: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 y <br /> � . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.7-10 1,1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I-yam-7) <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 /> 6 AIM.-7 <br /> �jq <br /> JOB ADDRESS/LOCATION !,Wt - .� 11VAdA � 01 )f.41- CENSUS TRACT 2f'D-OZ= <br /> Owner's Name QL Phone l�.- 0�� <br /> AddressCity <br /> Contractor's Name d , License # Phone <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 I <br /> Other / / -�" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIFE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL f, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Al <br /> Domestic/private Drilled Dia. of Well Casing AF <br /> .,.,�_.,..Do�esfie./p��1ic`.�"..�_ Drxven•_ _ . _��� Gauge`af-Casing"` ... _ . � .f� - _" _ ' <br /> , Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary - Type of Grout -- <br /> Disposal Other Other Information _._ t <br /> Geophysical Surface Seal Installed By: -- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> r <br /> PUMP .REPAIR: /-7 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 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 notify them 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 INSPECTIONNyK <br /> PRIOR TO G UTING ANDA INAL IN PECTIQN. ) TITLE ` c Cl <br /> SIGNED <br /> ARA . PL T' L 'ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I ' 1 <br /> APPLICATION ACCEPTED BY DATE 2 C <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS ECTIQ HAS II N INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i - <br /> 9 H 1426 Rev. 1-74 3/76 <br />