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r - SAN JOAQUIN LOCAL ffaifl DISTRICT <br /> FDF. OFFICE USE 1601 E. Hazelton Ave. ,-,Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77-IA6' # <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �P <br /> (Complte In Triplicate) �L0 3- <br /> Application is hereby made tolthe 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 RiYles and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOS ADDRESS/LOCATION\�Q-P�0 �\�o��t- /vD� �7�aB�'-^-�'�-g <br /> Owers Name l/ [ hone Sy9- 3�9(a <br /> city <br /> Address ' <br /> Contractor's Name License 8 ��p9/3Phone yjS�S-��J i <br /> t <br /> TYPE-OF WORK (Check):—NEW-WELL"�DEEPEN-/_T RECONDITION / /- -DESTRUCTION-/-T• <br /> PUMP INSTALLATION j_/ PUMP REPAIR / / � PUMP REPLACEMENT 17— <br /> Other / / ` <br /> DISTANCE TO NEAREST: SEPTIC TANK IfIA& SEWER LINES PIT PRIVY Il <br /> (� <br /> SEWAGE DISPOSAL FIELD A ' CESSPOOL/SEEPAGE PIT t OTHER O <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ,Q1PUBLIC DOMESTIC WELL 6�2J B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y, <br /> i <br /> Industrial A Cable Tool Dia. of Well Excavation �e2 _ <br /> Domestic/private I Drilled Dia. of •Well Casing <br /> Domestic/public I Driven Gauge of�Casing <br /> IrrigationGravel Pack ' Depth of'Grout Seal — <br /> Cathodic Protection 4 Rotary Type of Grout <br /> j Disposal - Other Other Information <br /> Geophysical - Surface Seal Installed B : <br /> PUMP INSTALLATIONt Contractor "�Z^ H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done - __V_ <br /> __ _- . - s Approximate- Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> cal <br /> 'J <br /> rict <br /> I hereby agree to comply with all laws and regulations owelle'construction.San joaquTnLoWithin Health t <br /> FIFTEEN DAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work on.a new well, I. will .fumish_.the San Joaquin Local Health District a <br /> above <br /> WELL DRILLERS REPORT of the well and notify them <br /> before <br /> belief. I WILL CALL FOR AeGROUTe <br /> andINSPECTION <br /> information is true to the best of my knowledgef <br /> PRIOR TO GROUTING AND NAL INSPECTION <br /> . TITLE <br /> SIGNED '- PLOT P ON REVERSE SIDE) — :4 <br /> FOR DEPARTMENT USE 1, <br /> PHASE I - DATzg—7 -� <br /> PPLICATION ACCEPTED BY i <br /> yADDITIONAL COMMENTS: PHASE II /FIN INSPECTION <br /> - -' PHASE II GROUT-INSPECTION IN SPhCTION BY, DATE <br /> .t <br /> INSPECTION BY _ DATE's <br /> 1177 <br /> I, E H 1426 Rev. 1-74 <br />