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PUMP REPLACEMENT: <br />' PUNT REPAIR: <br />DESTRUCTION OF WELL: <br />/ / State Work Done <br />17 State Work Done <br />Well Diameter Approximate Depth <br />6W/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUNT PERMIT Permit No. 7‘,...5-4,i9eci <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued evi2-7.' <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 />H.P. <br />JOB ADDRESS/LOCATION //45:11---'/Cas-ie_b( <br />Owner's Name <br />Address <br />Contractor's Name <br /> Ahcc.c/G <br />CENSUS TRACT <br />Phone <br />City ,5X-oLc-4Cvh <br />License itz„,79r Phone <br />TYPE OF WORK (Check): NEW WELL DEEPEN /1 RECONDITION f-T DESTRUCTION (7 <br />PUMP INSTALLATION 5' PUMP REPAIR / /--FUMP REPLACEMENT 17 <br />Other / / <br />DISTANCE TO NEAREST: SEPTIC TANK .75 SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> <br />INTENDED USE <br />Industrial <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />Geophysical <br /> <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />Cable Tool Dia. of Well Excavation /".2..., <br />Drilled Dia. of Well Casing <br /> Driven Gauge of Casing <br /> Gravel Pack Pack Depth of Grout Seal j'-e7 <br /> <br />X Rotary ..Xe---.,..e_ Type of Grout <br /> Other Other Information <br />Surface Seal Installed By: <br /> <br />>c <br /> <br />PUNT INSTALLATION: Contractor ,27' .27 <br />Type of Pump rreet,./ <br />Describe Material and Procedure <br />I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />pertaining to or regulating well construction. Within FIFTEEN DAYS <br />on a new well, I will furnish the San Joaquin Local Health District a <br />well and notify them before putting the well in use. The above <br />f my knowledge and belief. <br />and the State of California <br />after completion of my work <br />WELL DRILLERS REPORT of the <br />information is true to the <br />PRIOR TO GROUTING AN' ...01.N!..usagater <br />71014, SIGNED <br />I WILL CALL FOR A GROUT INSPECTION <br />TITLE <br />PLOT PLAN ON REVERSE SIDE <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY cpalk., <br />ADDITIONAL COMMENTS: <br />PHAS II GRO T INSPECTION/ <br />INSPECTION BY DATE <br />E H 1426' Rev. 1-74 <br />INSPECTION B <br />Ap <br />likammr- ..." <br />INSPECTIO <br />DATE <br />3/7c4=1 <br />DATE -17