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....SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif., <br /> ' <br /> Telephone:: ' <br /> p (209) 466-6781 <br /> i-. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 J4/kd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued fo77 <br /> (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 Joaquii <br /> County Ordinance No. '1862 and the Rules and Regulation(COT- <br /> f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> r ��,` 71 , 31- 1f <br /> Owner's NameC: ! ! v Phone <br /> Address .� . U6 [� Q City S/ VMA) <br /> Contractor's Name , E .ev , PHFA) License# 74462 Phone Z142 6 <br /> r <br /> '.TYPE OF WORK (Check) : „NEW. WELL / DEEPEN /_/ RECONDITION: / --/, DESTRUCTION /_ <br /> f. PUMP INSOLATION / / PUMP REPAIR / / RUMP-REPLACEMENT /_7 <br /> . Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK { SEWER LINES ,;..PIT. PRIVY srf <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f' <br /> i` PROPERTY LINE - PRIVATE DOMESTIC. WELL 1 PUBLIC DOMESTIC WELL <br /> INTENDED `USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> {> Industrial Cable Tool Dia.` of We11 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> x Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of' Grout <br /> Disposal Other Othez Information � • <br /> ` Geophysicai ..,Surface Seal Instal*led"By: , <br /> t ... <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. <br /> { PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIrR- / / State Work Done + <br /> ,.DES-TRUCTION OF WELL: Weil Diameter Approximate Depth <br /> Describe Material and Procedurd <br /> 6.7a <br /> ',I hereby agree to comply.'with 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 DRILLEA REPORT of the wel7`and notify them before putting the.-well in use. The above <br /> informatia s 'true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ; UTING AND : FIN I1jSPFCTj0. <br /> SIGNED ' TITLE <br /> z.' I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> } _ FOR DEPARTMENT USE ONLY <br /> '`PHASE I <br /> tAPPLICATION ACCEPTED BY DATE 6r <br /> ;,ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> :-'INSPECTION BY DATEal 7 INSPECTION BY E'/? DATE 19 . <br /> t . <br /> a ,E H 1426 -Rev. 1-74 <br />