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!! SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> u FM'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone• (209 ', 466--6781 j <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 /> Application is hereby made to the San Joaquin Local Health Distiict 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/LOCATION T = CENSUS TRACT <br /> Owner s s Name 4 <br /> (' k 1 S Phone Z <br /> Address Z-, ERM- O m E Es g Q -.-_4 qy43C20 <br /> Contractors Name �,. ��. P i License # �u Phone Z�S <br /> TYPE OF -WORK (Check): NEW WELL/� DEEPEN '/-7 RECONDITION /_7 DESTRUCTION �f <br /> PUMP INST LATION / / PUMP REPAIR /7 PUMP REPLACEMENT /rf n <br /> / - <br /> Other 7 .� <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p - <br />• SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER rte; <br /> PI OPERTY LINE - PRIVATE DOMESTIC .WELL TI PUBLIC DOMES . WELLf <br /> INTENDED US:V,;,'�a. 0'Y' TYPE OF WELL �; CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of Well Excavation /Y I <br /> Domestic/private Drilled Dia. of Well CasingtI <br />­­ _Domestic/public-,�-- ._ -Driven--- --- --,-Gauge-of Casing - l - , <br /> Irrigation Gravel Pack Depth of Grout Seal a .e.'...,._ <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other ' Othei-'Information <br /> Geophysical ; Surface Seal Installed BY: f <br /> PUMP INSTALLATION: Contractor +".- W <br /> Type of Pump `° H.P - <br /> . <br /> PUMP REPLACEMENT: L/ State Work Done <br /> .,. <br /> PUMP :REPAIR: � /7 State Work Done <br /> ES;TRUCTION OF WELL: Weld::Diameter pp ��.. <br /> j Approximate Depth <br /> Describe Material and Procedure <br /> .y <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 /> informat n is true to the-best of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO M2UTINQWD NAL NSPECTION. <br /> SIGNED Y um 2LL& TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> - -FOR DEPARTMENT-USE-ONLY <br /> PHASE I �{ <br /> APPLICATION ACCEPTED BY '1 DATE <br /> ADDITIONAL COMMENTS: \, ,a"-' ^ti i <br /> PEW, IIWINa INSPECTIO <br /> INSPECTION BY DATE 3 jZ= INSPECTION BY DATE <br /> t T <br /> i E H 1426 Rev. 1-74 /fes/ lv.r 1-74 2M <br />