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!/ SAN JOAQUIN LOCAL HEALTH. DISTRIC <br /> FOE OFFICE USE: 1E E. Hazelton Ave. , Stockton, C�, - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77p �o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pe i onstruct <br /> and/or install the work herein described. This application is made in. compli Q fta n Joaquin <br /> County Ordinance No. 1862 and the Rut nd RegulationA of the San Joaquin Local <br /> JOB ADDRESS/LOCATION �'T <br /> `--��CEN5US TEACT . <br /> Owner's Name Uj__1 0 A=X57Phone <br /> Address / /�✓City <br /> i. <br /> Contractor's Name � /-J S License "�3��Phona6 <br /> TYPE OF WORK (Check): NEW WELL'/ ./ DEEPEN ' _/ RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT. 17 <br /> Otherl 11 <br /> DISTANCE TO NEAREST: SEPTICjTANK 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 <br /> Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation f Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection 1 Rotary Type of Grout ; .. <br /> Disposal Other Other Information ' <br /> Geophysical . Surface Seal Installed„By,_:_ <br /> -- -- 4r <br /> PUMP INSTALLATION: Contractor zz <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . J-1 State Work Done <br /> PUMP .REPAIR: f / State Work Done <br /> �DES-TTRUCTION 'OFWELL: Well Diameter Approximate Depth 'A” <br /> - PP P <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health DI;txi,ct <br /> and the State.:of California pertaining to or regulating well•construction. Within FIF'TERN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Dfstri�'t <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 It(SPECTI.0 <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> SIGNED / TITLE ` ` <br /> D W.: PLAN 'ON RSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,.. DATE 7 <br /> ADDITIONAL COMMENTS: { <br /> PHASE II G INSPECTION PHAS fF INSPECTION :• <br /> INSPECTION BY INSPECTION B DATE �- <br /> 3/76 <br /> E S 1426 .8ev. 1..74 E . <br />