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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FGR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> rd Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin ' <br /> County Ordinance No. . 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4//?e)o _ CENSUS TRACT <br /> Owner's Name Phone,/ <br /> s <br /> Address 1-700 City QGK x <br /> Contractor's Name IC (f License #30213 Phone q&- &U7 <br /> TYPE OF WORK (Check) ; <br /> NEW WELL X DEEPEN /_/ RECONDITION' / -7 DESTRUCTION /_7 <br /> " . PUMP INSTALLATION41, — <br /> PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES Aw-f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE :-� PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic /private Drilled Dia. of Well Casing 6�� <br /> Domestic/public Driven Gauge of Casing 266 eyi c, <br /> Irrigation Gravel Pack Depth-tof Grout Seal - L70 / <br /> ----- --- <br /> Cathodic Protection Rotary Type of Grout F' -roa <br /> Disposal Other Other Information <br /> Geophysical a Surface Seal Installed By: AVOA Cid <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. T_ <br /> PUMP REPLACEMENT: J�/ State Work Done <br /> t <br /> ,PUMP .REPAIR: / / State Work Donee' r I <br /> DESTRUCTION OF WELL: Well' Diameter �`� F - Approximate Depth <br /> '4- <br /> Describe Material and Procedure <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 'coristruction. Within FIFTEEN DA�S <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 well and notify them before putting the well in use.. The above <br /> information is true to .the best.of my knowledge and belief. I WILL'-CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU G ANJO A F AL IP TION. - <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 'I <br /> APPLICATION ACCEPTED BY �9'Y'1 (29DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE I GROUT INSPECTION PHASE III/,FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATE 7-,17--77 <br /> F N T/7A n,.__ 1 z A 1 /77 "" 7M <br />