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'/ SAN JOAQUIN LOCAL ,HEALTH DISTRICT <br /> FOR•rOF 'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: -..(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 'UMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES, I .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 appXication 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 CENSUS TRACT <br /> Owner's Name AU f ) Al' _ Phone <br /> Address V A )-71 <br /> City L'SG/J./.Qvs.� <br /> Contractor's Name U "roV License # o2/✓0JaPhone $3t-b?R67 <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN 17 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR /-7—PUMP REPLACEMENT <br /> Other /_7 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s, =- 'PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool <br /> 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 x <br /> ` <br /> —.Disposal , ._, > Other Other Information �• <br /> Geophysical Surface Seal Installed By: ` <br /> PUMP INSTALLATION: <br /> Contractor .�07 0 <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done. 4 <br /> P TMPREPAIR: - ` - `-" "/ "-/ _11State Work Done <br /> &ES;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 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 FO A -GROUT INSPECTION <br /> PRIOR TO 9B <br /> QAUT;KGAN A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> F DE ART USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION FHA II/ AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> E H 1426 Rev. 1-74 1-7G Im <br />