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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- Z u » <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &a UL Z6 <br /> (Complete In Triplicate) `-t <br /> Application is`bereby made tolthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereintdescribed. This application is made in compliance with San Joaquin , <br /> County Ordinance No. 0C1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION //%� A JOZA :Z, /7 /7 CENSUS TRACT <br /> at ��N. <br /> Owner's Name /l� U4,0. Lala- Aa-,J T Phone <br /> Address ; 3 3 S'6 City <br /> Contractor's Name <br /> �� .�.� u� License #Ao 1-373 Phone36 3 <br /> 1 a <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/� RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION/ / PUMP REPAIR fi; PUMP REPLACEMENT /7 <br /> Other / / <br /> �J\ <br /> DISTANCE TO NEAREST: tSEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ! CESSPOOL/SEEPAGE PIT OTHER �. <br /> PROPERTY LINE - PRIVATE DO STIC WELL — PUBLIC DOMESTIC WELL W <br /> INTENDED USE TY E OF WELL I CONSTRUCTION SPECIFICATIONS <br /> 1 , <br /> If Cable Tool Dia. of Well Excavation <br /> Industrial I C1 <br /> Drilled Dia. of Well Casing <br /> Domestic/priva <br /> Domestic/publi � 1 Driven Gauge of Casing <br /> Irrigation �v 1 Gravel Pack Depth of Grout Seal <br /> Cathodic, Protection 1 ? " Rotary Type of Grout t <br /> Disposal( it; �s'_ I ; Other Other Information ' <br /> GeophysSurface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: 'Contrac56r iv ' <br /> Type of Pump i EAMD <br /> � A.P. a <br /> PUMP REPLACEMENT: j—/ State Work Done' <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Prockdure <br /> � y <br /> I hereby agree to comply with all laws and iegul ions of the San Joaquin Local Health District <br /> and the State of California pertaining to or reg la'ting well"construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them tbefiore putting the well in use. The above <br /> information is ylue to the beat of. my.knowledge hdAelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTog ANR A FINAti SPECTIO . <br /> TITLE <br /> SIGNED D WPB T- PLAN 'ON RE ERSE SIDE -17i` <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I DATE - �6 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION v PHASE III/FINAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY C'. J3 _ DATE /a- <br /> 3/76 2M <br /> E H 1426 'Rev. 1-74 -� <br />