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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOIx:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_S-/g'�n <br /> fiHTS PERMIT EXPIRES 1 REAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 k C26 b V1/ k-je - CENSUS TRACT <br /> Owner's Name x // Phone <br /> �l - 633 <br /> ,r <br /> Address CityX <br /> Contractor's Name I16. Ticense # Phone6 Z c18-0 <br /> - :1.. <br /> 'TYPE OF WORK (Check): NEW WELL /7 DEEPEN /-' RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Otherl /% — <br /> #. <br /> DISTANCE TO NEAREST SEPTIC'TANKSEWER 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 /> Industrial + 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 _ R <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ' <br /> Geophysical_ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> PUMP REPLACEMENT: , /_7 State Work Done <br /> PUMP .REPAIR:- .., S.ta.te--dWork-Done��E�,:r�l.L <br /> DES1RUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure? <br /> r <br /> Y 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 /> E 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 ue to the- t of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />' PRIOR TO GROUT N D FI NSP CTION. <br /> SIGNED. TITLE <br /> W PLOT PLAN ON REVERSE SID-ET <br /> PHASE i_ <br /> FOR DEPARTMENT USE ONLY { <br /> J <br /> APPLICATION ACCEPT BY DATE '-3-7� <br /> ADDITIONAL CONIl�4ENT5 (�•a-1l <br /> PHAQSKI <br /> SE GROUT INSPE ION `J PHASE III/FINAL i ECTION <br /> INSPECTION BY DATE W_ INSPECTION BY .. DATE �$•'�{] <br /> E.H 1426. <br /> Rev. 1-74 <br />