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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Permit No..; - A16 461 <br /> 76-15 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J-a9-76 <br /> ,Z?-6 S .. -`Fac � �8� GE��✓j. (Complete In Triplicate) (�3 -l7ca. C/ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein descri'bed. This application is made in compliance with San Joaquinf <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sa Joaquin�ocal Health District. <br /> JOB ASS/LOCATION "--fCEN5US TRACT <br /> Owner's Name . j d� Phone <br /> tom_. <br /> Address 7 .. .._ City 1 <br /> Contractoir',a Name -.License ` GL hone�v�/- l 1 <br /> 4 <br /> TYPE OF WORK (Check).: NEW WELL DEEPEN '/7 RECONDITION DESTRUCTION /_7 N <br /> PUMP INSTALLATION ' PUMP REPAIR -/ PUMP REPLACEMENT /_7 G <br /> Other / / . . . . . . <br /> L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD •----- CESSPOOL/SEEPAGE PIT moa f OTHER— <br /> PROPERTY LINH5�aPRIVATE DOMESTIC WELL :1!!�'006PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ., .--. —Cable-Tool —Dia.-of--We1l-Excav&tidh-` <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing1 <br /> Irrigatio Gravel Pack Depth of Grout Seal <br /> Cathodic protection Rotary Type of Grout ' <br /> Disposal Other Other Information ' ' <br /> - GeophysicalSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ' <br /> Type .of Pump ' H.P. <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP .REPAIR: <br /> 'Stattat <br /> e Work Done { <br /> DESTRUCTIONOF WELL: Well Diameter Approximate Depth <br /> Describe Mate Tal and Procedure <br /> a <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 j <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT. of the we'll and notify them 'before putting the..well. in.use.... The above i <br /> information is true to the-best'.of my..knowledge and belief. I WILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL_INSPE <br /> SIGNED ITLE /�j' �9-cam <br /> ¢ _(DRAVt PLg PLAN ON REVERSE SIDE) <br /> PHASE I -- <br /> FO DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Z ' INSPECTION BYy. _ DATE _ - -' (�j <br />