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e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: n 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Zr: <br /> THIS PERMIT EXPIRES 1 'SEAR FROM DATE ISSUED Date Issued 3-/�=?7 <br /> (Complete In Triplicates <br /> Application is ereby made to the Sacs 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 `Rule-a and Regulations of the San Joaquin Local..HealtT=District. <br /> G <br /> 71 <br /> JOB ADDRESS/LOCATIONJCt ' ' W _-_ I <br />• Owner's. Name Phone <br />� Address � � a �` City <br /> Contrgctpr's Name icense Fhorte j ^�► �1 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /_7 DESTRRUCTION /� <br /> PUMP :INSTALLATION / PUMP REPAIR -7 PUMP REPLACEMENT /7 <br /> Other %/ <br /> DISTANCE TO ST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISFOSAL FIELD CESSPOOL/SEEPAGE, PIT OTHER <br /> PROPE TY LUM - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENIAD USE TYPE 0 WELL CONSTRUCTION SPECIFICA' S <br /> Industrial Z.. Cele Tool Dia, of Well- Excavation67, <br /> Domestic/private Drilled Dia. of Wall-Casing <br /> Domestic/public R`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 By /� -f'`"` <br /> PUMP INSTALLATION: Contractor <br /> Type of pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP -.UPAIR: /_ State Work Done <br /> ,SES TRUCTION OF WELL: Well Diameter >- ,.Approximate Depth _ <br /> Describe Material and Procedure <br /> I hereby, agree to comply with all laws and regulatk9a o San Joaquin Loca1 Health •District <br /> and the State of California per%ainiu to.or regulating wellconstruction. Within FIFTE9X DAYS <br /> after completion of my work on a new w , •I will furnish the San Joaquin Locaf Health District a <br /> WELL DRILLERS REPORT of the well~end notify them before putting the .well in use. The Above <br /> information is true to the-best of- my-knowge and belief-. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG D A FINAL5 INSPE IO <br /> SIGNED TITLE <br /> „ D PLAN ON SIDE I: <br /> DEPARTMENT <br /> USE Y <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE ZI 7 <br /> ADDITIONAL COMMENTS: s <br /> PHASE If GROUT INSPECTION PHASE I L INSPOrl <br /> INSPECTION BY DATE INSPECTION BY ...DATE <br /> 3/? .:. <br /> r <br /> E H 1426 Rev. 1-74 <br />