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SAN JOAQUIN LOCAL HEALTH DISTRICT ti . <br /> YFOF OFFICE= USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> ; <br /> Telephone: (209) 466-6781 � µ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 111 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> At (Complete In Triplicate) <br /> rT)T <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. 18622 and the Rules and Regulations of the San Joaquin Local Health. District'. <br /> JOB ADDRESS/LO ION / �� f CENSUS TRACT <br /> Owner's Name ��fiMQ�� -� G � Phone <br /> Address City <br /> Contractor's Name License Phone � �. 9;Z <br /> i ec <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION 17 DESTRUCTION /-7 <br />` PUMP INSTALLATION / / • PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 /> - D-ome s tic/private i L—Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing e--f6,e <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ___,,=, Rotary Type of Grout <br /> Disposal Other Other Information -RY <br /> Geophysical ,Surface Seal Installed BY: ` <br /> � <br /> PUMP INSTALLATION: Contractor F PLA",a- o/Z 8f 7 <br /> Type of Pump A-g--e- H.P. �^ <br /> PUMP REPLACEMENT: / / State tWork Done <br /> PUMP ,.REPAIR: � <br /> AIR: / St to Work Bonede <br /> ES TRUCTION OF WELL-:"r WeliVDiameter P;�Croe-lxf�rto Depth <br /> Describe Materia_ lwand Procedure- T� <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 G OUTING AN 6A FINALiINSPECTION. , <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> [ <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> t <br /> APPLICATION ACCEPTED BYX DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTIO <br /> INSPECTION BY DATE -7 -7 INSPECTION BY DATE S' -7 7 <br /> 04- _ E H 1426 Rev. 1-74 �//�GlA�� a�� �, I0 <br />