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0 - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOF�rOFFI E USE. 1601 E. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 76- 6 L O <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS AOCATION Od4bv- W, T1- X A&,/- F."e ,l�e� -Ao(CENSUS TRACT 1 i-7--0sV--0I <br /> Owner Q s Name _ �C� ✓� f ✓l( Phone 1 <br /> Address 1 Sj T;--,,j vy, A-a tea City <br /> Contractor's Name �,L. C� License # /� .7� fhone '�- � <br /> TYPE OF WORK (Check): NEW WELL_ DEEPEN/7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR LX/ PUMP REPLACEMENT <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 /> P e y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of .Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information a <br /> Geophysical Surface Seal Installed By: <br /> PUNP INSTALLATION: Contractor - <br /> Type of Pump H.P. t <br /> PUMP REPLACEMENT: %/ State Work Done <br /> k PUMP '.REPAIR:_ / State Work Done & <br /> ,RES TRUCTION OF WELL: 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 Sari Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and p ify them before putting the- well in use.. The above <br /> information is .true to the best of- my —and bel of.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AN ]FINAL INS �am, <br /> SIGNED - E <br /> {D P T ON IDE <br /> FO: DE TMENT US ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 1-74.,2M <br />