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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS�r'OFFTCE USE: 1601 E. Hazelton Ave, , Stockton,, Calif. <br /> Telephone:,, (209) 466-6781 <br /> APPLICAZION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y-�p yyo <br /> t <br /> s THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued sin 7� <br /> (Complete In,Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or installthe work herein described. , This application is made in compliance with San. Joaquin <br /> No <br /> County Ordinance 1862 and the Rules and Regulations of: the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION.; • :1�743 Car �-rt efr�-i/ :.CENSUS TRACT i <br /> 1 154- <br /> f� OwcEer s Nam ��� =� Phone <br /> Address <br /> Address 'Yll� ,.,...— �city <br /> . �5-- � <br /> Contractor's Name � '� � License # /p hone �?6% <br /> u.. F <br /> TYPE OF.WORK -(Check): NEW WELL '/? .DEEPEN J7 RECONDITION /7 DESTRUCTION /7 <br /> _ PUMP INSTALLATION /_'.PUMP REPAIR &_7 PUMP REPLACEMENT <br /> other <br /> DISTANCE TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHER <br /> y PROPERTY LINE -- PRIVATE DOMESTIC WELL ` L- PUBLIC'DOMESTIC WELL �! <br /> ► INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well 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 Other Information <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION::. Contractor 64 , <br /> Type of Pum H.P. }3 _ <br /> PUMP REPLACEMENT: / . / State Work Done <br /> PUMP:REPAIR: LF State Work Done Maj2ZAL. <br /> j2ESTRUCTION OF WELL: Well Diameter Approximate Depth <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 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 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.knowl dge belief.. I"WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> I" SIGNED ` . ITLE. <br /> PT PLAN ON RE RSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 <br /> . ADDITIONAL COMMENTS: <br /> z PHASE IT G N EC N PHAS III F NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION- BY DATE Z <br /> E H 1426 Rev. ^1-74 I-74 2M <br />