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r a� <br /> v1d SAN JOAQUIN LOGAL xHEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _s-y/[J <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 nd Re tn,ns of the San Jjoaqluiin Local Health District. - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address f City <br /> } <br /> Contractor's Name 0, License # Phone .1.2-/43/ <br /> y <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /-7- DESTRUCTION / 7� j <br /> PUMP INSTALLATION '/ / , PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SG SEWER LINES 5_a - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -5-01 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 /> :::�omestic/private 4—Drilled Dia, of Well Casing zS <br /> Domestic .Driven <br /> /public .- __ , Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �-ay <br /> Cathodic Protection '* Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> - Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor 'I I <br /> f <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: . / / State Work Done- ''' �} <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION--OF-WELL-:---We11TDiameter-__ A ;,.Approximate-Depth <br /> _ T 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 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 the -well 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 GR UTING AND- A FT.NAL INS CTION. <br /> SIGNED <br /> ITLE , <br /> (DRAVELT LAN 'ON REVggSE SID .' . <br /> R DEPARTMENT USE ONLY <br />.PHASE I r . ,� <br /> APPLICATION ACCEPTED BY DATE `r <br /> ADDITIONAL COMMENTS: <br /> PHASE .I'I 22UTXZINSPECTIO PHASE, II/FINAL INSPECTION <br /> INSPECTION B DATE V G INSPECTION BY- W DATE <br /> E H 1425 Rev. 1-747 ;�.y`,, 1v"-P ,, J-/67 4 �3/7 2M <br />