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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —i-MICE USE: 1601 E. Hazelton-Ave.', Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7�� <br /> THIS PERMIT EXPIRES-. 1 YEAR FROM DATE ISSUED Date issued <br /> �S c�0 5� <br /> f (Complete In Triplicate) r cr3-LSV-0s <br /> ` 'Application is hereby made to tha 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 /> 7S'f ( E- H c 64-tu1 Ay <br /> , OB ADDRESS/LOCATION ig Alf's IS A n�- y Mdr. 01 o rrr,,- r j,4 7e,(CENSUS TRACT <br /> . . Owner's NamEac �'"" rr1��f Phone <br /> � Address c.1d���Y'_2®.�p ,• • �1''/r, �G"}�.� ,(G,t L .,,_.... City <br /> .1 <br /> Contractor's Name License # _:Phone <br /> � 1 <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN "/-7 RECONDITION /-7 DESTRUCTION /j <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-(7 PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 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 Cable Tool Dia. of Well Excavation <br /> DasCic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> , CL Irrigation ^.,Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br />' Disposal Other Other Information <br /> —GeophysicalSurface Seal Installed B <br /> PUMP .INSTALLATION: Contractor <br /> Type. of Pump H.P. S� <br /> PUMP REPLACEMENT: State Work Done <br /> MP <br /> / / { <br /> PU ,.REPAIR: <br /> �/ State Work Done <br /> ES:TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> k I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br />!t 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALrIN PELT 'ON. <br /> SIGNED _ TITLE <br /> (D LOT PLAN N REVERSE SIDE <br /> -'`;FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION� ACCEPTED BY DATE�6--���� <br /> i ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION ' PHASE II FINAL INSPEC ON <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br /> t ,� 14 <br />