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_.�► . ,; � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> N OE OFFICE U E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _7735/4-w <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's 2Name � G2 Phone() <br /> Address ZP(U/ [�-G(/ City <br /> Contractor's Name gLi7en <br /> se4��� 7r Phone- ��- <br /> �� l <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION / / DESTRUCTION /-T <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4-'Domestic/private A"Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection l--Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 6-111-el- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAI / / State Work Done <br /> 1/ <br /> ES•TRUCTION OF WELL: Well Diameters s Approximate Depth &� <br /> Describe Mate ial and Procedure a 01` <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health niarrict <br /> 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 thewellin 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_,GVUTING AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> !"(DRAWPLOT PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 01 <br /> APPLICATION ACCEPTED BY DATE .3 �d <br /> ADDITIONAL COMMENTS: <br /> P II GR UT INSPECTION P SE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATEojy <br /> _. <br /> 376 2M <br /> E H 1426 Rev. 1-74 <br />