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f <br /> SAN eAAQUIN.10CAL.!HEALT� DISTRICT <br /> t FOR OFFICE USE: 1601 E:�,izelton Ave. , Stockton, Calif. 1,x' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> C 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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 23 .`Z OLL CENSUS TRACTOwner's Name Phone �j7 _ 1f�p 'Z <br /> Address <br /> city <br /> ,..�.�.� y ,. T G iY <br /> w Z G <br /> �a^ ZoeContractar's Name License �f/ 32� Phone2 <br /> 5/S <br /> TYPE OF�WORK"('Clieck) : ADEEPEN '/—/NEW WELL _ <br /> N '/ / RECONDITION / / DESTRUCTION /-7 <br /> " PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> DISTANCE TO NEAREST: ;SEPTIC TANK ldy SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE_- RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF,WELL . A. , ' 1; CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 'Voo`i' � r._-Dia. of Well Excavation p--� <br /> Domestic/private Drilled Dia. of Well Casing "' oo4.4_S`Ti C <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S Z <br /> Cathodic Protection - Rotary Type of Grout <br /> . .Disposal Other Other Information <br /> Geophysical n Surface Seal Installed B :- r X c T" <br /> QPUMP INSTALLA� <br /> Type of Pu1% H.P. <br />' PUMP REPLACEMENT.- , <br /> (f, <br /> fId� SWork Done <br /> CAL <br /> PUMP ,REPAIR: sA Ja 1(INLMj'47ork Done <br /> .y u � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 7=0eP <br /> Describe Material and Proc—duce <br /> I hereby agree to comply with all laws and regulations of the San, Joaquin Local Health District <br /> and the State of <br /> California pertainingto or regulating well ��construction <br /> g , g Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wiii` 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 GROUTING AMID A FINAL INSPECTION.'Y�, <br /> SIGNED TITLE eye_ / i;l <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION'ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TTI/FINAL INSPECTION <br /> INSPECTION- BY DATE INSPECTION BY DATE <br /> E H 426 Rev. I-74 1177 2M <br />