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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <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 �dZ171 <br /> (Complete In Triplicate) (i✓ G <br /> Application is herebymade to the San Joaquin Local Health District for a t Zz—uc 7/ <br /> q permit to construct <br /> and/or install the work herein described. This application is made iA­compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -��� CENSUS TRACT <br /> Owner's Name ' Lc_ Phone 2 /� <br /> i <br /> Address C,0- � City <br /> ContraQtor's Name C-V License 0: / Phone �� <br /> __ tl <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION /SUMP REPAIR/ / PUMP REPLACEMENT f-J <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Com'✓/rte Zr (i,•i/J <br /> Type of Pump . -- -- -�� � `- 'S� H.P. Z <br /> PUMP REPLACEMENT: / / State Work Done y..S 7-7�1'711. _7 Z 6---7 f <br /> PUMP REPAIR: / / State Work Done S�� ��- Gc'z-Z_Z_ <br /> DESTRUCTION 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 San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above ; <br /> information is true to the best of• my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. j <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE �1� <br /> DRAW PLOT PLAN ON REVERSE SIDE) toe <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY r,�,r DATE <br />'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ' I FIN .INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE r I <br /> E H 1426 Rev. 1774 <br /> 1117. <br />