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F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. \� <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT E7(PIRES. 1_YEAR FROM DATE ISSUED Date Issued <br /> ,a... (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"Lacal Health District. <br /> JOB ADDRESS/LOCATION i5_3 7 ,2D CENSUS TRACT <br /> Owner's Name Phone <br /> Address City S'TifT.J - <br /> Contractor's Name _ 'roe; _A2Aow"e3 . .�.� License # 2=C) 1 7Phone zj/,�L /y,;;L31 <br /> TYPE OF WORK (Check) NEW WELL DEEPEN/7 .RECONDITION /? DESTRUCTION / <br /> PUMP INSTALLATION �_7 PUMP REPAIR /_7PUMP REPLACEMENT /7 <br /> Other .L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL r11 <br /> ,. -.,INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing ZVp <br /> _ Domestic/public 'Driven Gauge of Casing �- <br /> rigation gravel Pack jDepth of Grout Seal #- <br /> Cathodic PrIl�o <br /> otection _ tary Type of Grout' _ � <br /> Disposal1 . _ Other Other Ifarmation <br /> Geophysical Surface Seal Installed BX. <br /> PUMP INSTALLATION: Contractor , ° `R C <br /> Type of Pump - JO/VA/l_- E H.P. <br /> Vj <br /> PUMP REPLACEMENT: / State Work Done-A-r <br /> � r <br /> PUMP :REPAIR= L7 SC to•Work,Done � <br /> r <br /> &LSTRUCTION OF WELL: Well Diameter �'� -- __ �' ^ Approximate Depth ,S.0 ` <br /> Describe Material and Procedure - XhA,0 b Al'Ra g/1-1 <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 regulati,4"well•'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well I1,;will ftirdishtthe `Sai: Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting,.'the..well in.use. Thee�above <br /> information is true to the best of my knowledge and, belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> } SIGNED TITLE D,6144z <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> i ADDITIONAL COMMENTS: 5" <br /> FHAS!!1�11 GROUT INSPECTION HASZ_ IWFINAL INSPECTION , 7r <br /> INSPECTION BY DATE _ = INSPECTION BY DATE t7 <br /> Fy <br /> E H 1426 Rev. 1-14 1774 2M <br />