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rs, "`• SAN JOAQUIN LOCAL 'HEALTH DISTRICT �� <br /> ,F "OF CE USE: 1601 E. Hazelton Ave. , Stockton', Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No�7/a QQ <br /> THIS PERMIT EXPIRES 1 'YEAR+RROM DATE"IS"SUED DateIssued 9/6.7 7 <br /> I (Complete In- Triplicate) _ Y <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 SanrJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the •San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name me) n Pe--4!e y to Y'r'3°C Phone , <br /> Addresst 6 <br /> �i[t�rJo City 1 � . <br /> Contractor's Name License # /P—hone <br /> TYPE OF WORK (Check): NEW WELL'/7/ DEEPEN /7 RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP ENSTALLATION /% PUMP REPAIR /$q PUMP REPLACEMENT /7 <br /> Other /% <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Gl <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Industrial Cable Tool Dia. of Well Excavation �} <br /> Domestic/private Drilled Dia. of Well Casing C <br /> Domestic/public- Dri-.LQLl. Gauge_of -Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection " Rotary Type of Grout <br /> Disposal ! Other _`Other Information - �( <br /> Geophysical _ Surface SeaT'Ynstalled By: <br /> UMP INSTALLATION: �, Contractor' <br /> Type of} Pump i / H.P. y <br /> PUMP REPLACEMENT: t <br /> / Stata Work Done <br /> PUMP .REPAIR: State Work Done <br /> ➢ES,TRUCTZON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the. San Joaquin Local Health District 1 <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 <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 owled an elief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUZING AND A FINAL INSPE <br /> SIGNED TLE <br /> # RA PLO P ON RE E SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> AACATION ACCEPTED BY' ATE <br /> IONAL COMMENTS: - - - - - _ <br /> PHASE I T..IN PEUZION�. HASE� II/FINAL 3 SPECTYOI <br /> INSPECTION BY - DATE INSPECTION BY DATE /4 xi <br /> Y. •E-.H .Lt26 Rev- 1-74 x'` 0" b/77 9wr el <br />