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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOPS OFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.76- <br /> 76,E 6.s 1a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DAVE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made' to the Sass 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Heal.th' District. <br /> JOB ADDRESS/LOCATION ® 4 (1 <br /> CENSUS TRACT <br /> Owner's Name I I» Phone -. 3 ] 7 <br /> Address D L I" R City 7lfc�lYff��/� <br /> Contractor's Name, -y / y „ License #..5'u� Phone gzl7 a 32 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / * 'itECONDITION 'f_7 DESTRUCTION-./-7., <br /> PUMPNS ALLATION PUMP REPAIR17 PUMP REPLACEMENT <br /> Other <br /> fi <br /> DISTANCE TO NEAREST: SEPTIC TANK, /09i SEWER LINES <br /> PIT PRIVY <br /> I SEWAGE DISPOSALTIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY- LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of ,Well Excavation 10 <br /> Domestic/private Drilled Dia. of -Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> f Irrigation Gravel Pack-- Depth-of Grout Seal <br /> F Cathodic Protection Rotary Type of Grout <br /> Disposal _.- Other _ Other Information <br /> 4 Geophysical ' Surface Seal Installed By: <br /> € PUMP INSTALLATION: I -� <br /> Contractor ��(,'j"76 �. <br /> Type ..'of <br /> pump--H.P. . <br /> PUMP REPLACEMENT: E� <br /> IS tate 'Work Done <br /> t PUMP '.REPAIR: <br /> / / `State Work Done <br /> I DESTRUCTION OF WELL: s Well Diameter Approximate Depth <br /> i Describe Material and Procedure . . . . . . . <br /> I hereby agree to comply with all law's 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 anew 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 t6- the-best-of- my knowledge _and belief_. I WILL CALL.FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND 'A? I:NAL INSPECTION: <br /> SIGNED ` ITLE �z <br /> PLOT ON REV RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION' ACCEPTED BY DATE <br /> 4 ADDITIONAL.COMMENTS: - <br /> PHAS AROW INSPECTION PHASFj III FINAL INSPECTION <br /> INSPECTION BY DATE — r• INSPECTION BY DATE <br /> E H 1426 $ 1.'74 <br />