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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2-0 <br /> Application is hereby made to the San Joaquin Local Health District for a per it^oc onstruct. <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> �V� Ordinance No. 1862 d the Rules and Regulations of the San Joaquin Local Health District..' <br /> JOB ADDRESS/LOCATION _rpekt d CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City Ripon <br /> Contractor's Name License # <br /> L 2Q= 0734 Phone 248-8817 <br /> TYPE OF WORKCheck)�� .� �. =-�..•-,.._-�_ -.�.�-- �-�- w . --._ <br /> { NEW WELL/? DEEPEN -/r/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR/$/ PUMP REPLACEMENT % f <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRI <br /> VY <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 /> Domestic/private ( Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Gauge of Casing <br /> ,X Irrigation Gravel Pack Depth of Grout Seal <br /> • �z <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done ; <br /> r <br /> PUMP .REPAIR� <br />_- --. - ._._. - _/7/State. Work Done <br /> DESTRUCTION 'OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Deptht <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District `s <br /> and the State of California pertaining to or regulating well"construction. Within FIFTERN 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 i' true to the-best of my- knowledge and belief, I WILL CALL FOR.A GROUT I1SPECTI(3T <br /> PRIOR TO GROUTING AND A FINAL INSPPCTION, <br /> SIGNED J <br /> TITLE ;. <br /> D W P - PLAN ON WRbE S IDE <br /> PHASE I FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE Y ` <br /> ADDITIONAL -OMMENTS: _ . <br /> PHASE II RQUT iN$PECTION PHASE FINAL INSPECTION _ 1 <br /> INSPECTION BY . DATE INSPECTION BY G� DATE + <br /> .. - 2-7 7 <br /> E H 1426 Rev.,1-74 . <br />