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SAN JOAQUIN LOCAL HEALTH DISTRICT # <br /> 3 <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 7- 7VP11 <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J--tea-'7 7 <br /> i (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 Name Phone <br /> ' 1 <br /> Address �. City I l) <br /> Contractor's Name V t M4 I WEt (,( � Nr License it -/ 6- 17 ' <br /> 60Phone Z <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION / / DESTRUCTION /_7PUMP INSTATION / / PUMP REPAIRLACEMEN <br /> PUMP REP —T <br /> Other / <br /> / . /? <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LIPES PIT PRIVY <br /> SEWAGE DISPO Al FIELD Q ' 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 a`� ► <br /> Domestic/private E Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing t T/e � <br /> ` Irri aon,ti <br /> a g, Gravel Pack Depth of Grout. Seal rj' <br /> Cathodic Pr_o'tection Rotary ? -0. Type of Grout L /y(15IVT <br /> .Disposal Other' Other Information f <br /> Geophysical ---"Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a H.P. <br /> PUMP REPLACEMENT: / / Sate Work Done _ <br /> PUMP REPAIR: / / State: Work�Done { <br /> DESTRUCTION OF WELL: Well Diameter ` <br /> Approximate Depth•` . F <br /> Describe Material and Procedure ti <br /> I hereby agree to comply with all laws and regulations of the San_J.oaquin Local Health District <br /> and the State of California pertaining to or regulating well 'coristruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish t'he San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the. weltin-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 AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> -- -- _ _-,-{ .-PLOT_PLAN:ON REVERSE'-SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II S TION P-HAS' I /FINAL ZNSPECTIO' <br /> INSPECTION BY DA+ 7 INSPECTION BY DATE <br /> E H 1426 Rev. 1- 4 ��Gr li✓c�`JS � � 1l�i� �1� �i"/�l�l �T�'47y AW _ � � <br />