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,10 Al AN JOAQUIN LOCAL HEALTH DISTRICT 3 <br /> FOE OFFICE USE. , / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v 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 /> 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/LOCATION LG' Aol <br /> ,r CENSUS TRACT <br /> Owner's Name h �5 2v i�,t ✓�i100f Phone <br /> Address City �- t44 . . <br /> Contractor's Name License # one <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /,1(/ PUMP REPLACEMENT /-7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - PRIVATE bOMESTTCN <br /> C WELL PUBLIC DOMESTIC WELL 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �} <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled <br /> 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 <br /> Type of Pump 01 gym, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 <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 m knowledge nd�belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTING AND A FINAL INS ,fir, <br /> SIGNED ITLE <br /> PD T ON RSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY TE -g -j, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E II AL INSPECTION <br /> INSPECTION BY DATE INSPECTIO ATE ZS- y <br /> - : <br /> E H 1426 Rev. 1-74 3/76 2M :/ <br />