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f <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,.OFFICE USE: '''. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.2" ,i)6 Flo <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. 1862and the Rules and Regulations of the San Joaquin Local Health District. <br /> ` <br /> JOB ADDRESS/LOCATION / L CENSUS TRACT <br /> Owner's Name Phone <br /> Address �� (3 /�--t�` CC�c, City C6� <br /> Contractor's Name License &M6026 hone -1;3" <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <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 (V. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing q <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: <br /> PUMP INSTALLATION: Contractor 4 � <br /> Type of Pump H.P. 7 <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 DAIS <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 CA4 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND NAL IjqSPECTIO <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -27 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOVLPHASE II FINAL NSPECT ON <br /> INSPECTION BY DATE I Al <br /> INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1177 - 2M <br />