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✓J �<� ," SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: VVV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> L (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 Regulat ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7�' CENSUS TRACT <br /> Owner's Name Phone <br /> Address L 4 City j7,yJ6-7c <br /> Contractor's Name License #.VZOA Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION _0 PUMP REPAIR 1-7 PUMP REPLACEMENT /f <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 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: <br /> PUMP INSTALLATION: Contractor /, X47 22=(e <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> PES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -i <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 DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 AN INAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -� DATE - T, <br /> ADDITIONAL COMMENTS: ' <br /> PHASE I 'ROUT INSPECTION PHASE/AXKLFINAk INSPECTION o <br /> INSPECTION BY d�VDATE INSPECTION BY DATE — 1, <br /> E H 1426 Rev. 1-74 <br /> 1-74 ZM <br />