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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76" 343 4,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-10- <br /> (Complete <br /> l0-(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 /> JOB ADDRESS/LOCATION / .9 Z/ © -5 d ,� j&/V '� _ CENSUS TRACT <br /> Owner's Name &-va-Z dl z"e o zO l' /r ---- Phone <br /> Address Q 50 ,eAj 1A /✓ City AS6A LO <br /> Contractor's Name/-r`/ L,r _ ORVIV, y1fedU�'/ License #2.h"*7Z7,4hone . &1*5-36j <br /> TYPE OF WORK (Check) : NEW WELL/i�DEEPEN /_/ RECONDITION / / DESTRUCTION /7 r <br /> PUMP INSTALLATION / / 'PUMP REPAIR -/ / PUMP REPLACEMENT ' /7g. = t J <br /> other — <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK -20 SEWER 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 _ 1.7- 4%j!�o <br /> Domestic/private Drilled Dia. of Well Casing _ Z <br /> Domestic/public Driven Gauge of Casing y�"a <br /> Irrigations ravel Pack ­ Depth of Grout Seal <br /> Cathodic Protection �/ Rota'ry Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By -- _ <br /> PdP INSTALLATION: Contractor <br /> Type of Pump4 H.P. <br /> PUMP REPLACEMENT: . / /...,, State Work Done <br /> PUMP REPAIR:. / / State;Work Done - - - J <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth O Q <br /> Describe Material and Procedure <br /> Pe <br /> I hereby agree to comply Vith 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 INSPECTION <br /> PRIOR TO GROUTING D A FIN INS ION. <br /> SIGNED TITLE ti I <br /> PLAN 'ON RE ERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/ N4 INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY , DATE <br /> E H 1426 Rev. 1-74 <br /> 3/7b 2M ! <br />