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ISA JOAQUIN LOCAL HEALTH DISTRICT <br /> F„Q Or• ICE US E 1601 E. Hazelton Ave. , Stockton, Calif.- . <br /> Telephone:p (209) 466-6781 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No�:/Q <br /> 6THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q/492 7 <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 /y.1 P Vd Sa / CENSUS TRACT <br /> f' <br /> Owner's Name -Z g Q it Phone <br /> Address S"o City <br /> Contractor's Name j/4// f,/�� % r License #.t~��Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 12,5— SEWER LINES _j 1 S- - PIT PRIVY _p-- <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 /> �. <br /> Industrial Cable .Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing �� r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ' Gravel Pack Depth of Grout Seal .Su F T <br /> Cathodic Protection _� Rotary Type of Grout <br /> Disposal Other Other Information r� <br /> Geophysical Surface Seal Installed B : V <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 well in use.. The above <br /> information is true to the best of my owledge and belief. I WILT. CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS E ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> - <br /> FOR DEPARTMENT USE ONLY c� <br /> PHASE I <br /> APPLICATION ACCEPTED,.BY""- DATE �. <br /> ADDITIONAL COMMENTS: j 4 e4 <br /> PHASE GROUT INSPECTION PH4SE INAL SPECTIO <br /> INSPECTION BY DA'C`Ir' =ZX ., INSP-ECT ON�`BY- y <br /> 2M--"7T <br /> E H 1426 Rev. . 1-74 6177 , <br />