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6 L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �» <br /> FOF OFFICE USE: `° '' =1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 ��� �y,�a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedevL --7 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 �Iations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q CENSUS TRACT <br /> Owner's Name 77� [ Phone <br /> Address Ci <br /> Contractor's Name e ,.License V!;6 6 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /�EEPEN / RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION / UMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L NES 4PIT PRIVY �tSy <br /> SEWAGE DISP AL FIELD i�- CESSPOOL/SEEP�GE PI.T �-s�3Z OTHER --• <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL L5_ PUBLIC' DOMESTIC WELL �--' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation JFOF <br /> , <br /> ommestic/private Drilled _ Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack-4 Depth of Grout Seal <br /> Cathodic Protection ry Type of Grout' Q/V <br /> Disposal Other Other Information f; <br /> Geophysical Suxface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ! .� <br /> PUMP REPLACEMENT: / / State Work Done <br /> d <br /> PUMP ,REPAIR: / / State Work Done <br /> IJL,D s�,�t L A 66.5-V Iie A/i � /I � <br /> DESTRUCTION OF WE L: Well Diameter Approximate Depth <br /> 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 /> info a 'on is true to t y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR G UTING AND N 0 <br /> SIGNEDA TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ AL INSPECTION <br /> INSPECTION BY DATE B INSPECTION BY 27 DATE 27.1177-. 2K <br /> =— <br /> E H 1426 Rev. 1-74 <br />