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A -- <br /> CD •� <br /> /11L7 SAN JOAQUIN LOCAL fdEALTH DISTRICT <br /> FOErQFFCf'; USE: `GV�f 1601 S. Hazelton Ave. , Stockton,, ,Ca]if <br /> Telephone: (209) 466-6781' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL- 7-Z,j�a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -11 <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 Q,6 6 5Z j CENSUS TRACT <br /> Owner's Name r'aa_ Phone <br /> � AddressOF�0 City <br /> Contractor's Name <br /> License # f93��hone <br /> k <br /> TYPE OF WORK (Check) : NEW WELL '/? DEEPEN '/? RECONDITION /? DESTRUCTION <br /> AL /f <br /> C PUMP INSTLATION PUMP AFFAIR PUMP REPLACEMENT /? <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I 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 <br /> Dia. of We1'1 'Casing <br /> f Domestic/publicDriven Gauge of Casing <br /> I Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of G <br /> i <br /> 3 Disposal Other <br /> rout <br /> Other Information <br /> -Geophysical Surface Seal Installed B <br /> E <br /> PUMP INSTALLATION; Contractor 4:, <br /> 4 Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: L_1 .S'tate Work Done <br /> PUMP .REPAIR: State Work Done <br /> �►�1 ` �,. <br /> ESTRUCTION OF WELL: Well Diameter ' <br /> Describe Material and Procedure Approximate Depth <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 ofmy 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 f. m 1 <br /> PRIOR knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION k <br /> ROUTI G AND INS E N. <br /> SIGN ' <br /> � TITLE <br /> DRAW PLOT PLAN REVERSE SIDE �'— <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY d 'j <br /> ADDITIONAL COMMENTS: DATE '04 <br /> PHASE II GROUT INSPECTION ; PHAS I I FI INSPECTIO <br /> INSPECTION BY- DATE INSPECTION BY DATE <br /> 5 <br /> E H 1426 Rev. 1-74 <br /> - 1-74 W <br />