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i� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP. OFFICE USE: 1601 E_ -Hazel-ton Ave. , Stockton, Calif. <br /> 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 ! CENSUS TRACT <br /> Owner's Name Phone Z 9z_ 71672 -_ <br /> Address 5/ 7 744, <br /> City .1—&2 <br /> Contractor's Name / f License # 744,42 Phone aW-,z• 5 27 J <br />, TYPE OF WORK (Check) : NEW WELL __ <br /> DEEPEN / / RECONDITION /_� DESTRUCTION /7.7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT `;/? <br /> Other / / jII <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY } <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X_ Cable Tool Dia, of Well Excavation / <br /> Domestic/private Drilled Dia. of Well Casing <br /> 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 1 <br /> Geophysical y Surface Seal Installed By: <br /> f <br /> PUMP INSTALLATION: Contractor. <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work:,Done , <br /> PUMP �.REPAIR: / / State Work Done <br /> DESTRUCTION 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 REPO&T,c� the w�•1 and notify them before putting the..well in use.. The above <br /> information-is_trueto.,-the b.�_t of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO'GROUT Dr_AZf A SPCT ION. I <br /> SIGNED--"- <br /> _ . / �_ - TITLE <br /> .� O pRAV PLOT PLAN ON REVERSE SIDE) j <br /> PHAS , ,� t FOP, DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEJul FINa INSPECTIO <br /> INSPFCTI'ON BY DATE INSPECTION B� DATE <br /> • `� <br /> E -H 2426 Rev. 1_76 17I7 .. � 2M � <br />