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- (a"� �a 4. SAN JOAQUIN LOCAL HEALTH DISTRICT `- <br /> FOA�OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS/y <br /> THIS PERMIT EXPIRES l 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 /> .TOB ADDRESS/LOCATION CENSUS TRACT 0'?1- fd 1131 <br /> Owner's Name .e revv Phone <br /> 04, <br /> Address L si City <br /> Contractor's Name License # / �= hone + 3• ?� �' <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/—/- RECONDITION /-7 DESTRUCTION _� <br /> PUMP INSTALLATION /_/ PUMP REPAIR /T PUMP REPLACEMENT /7 S <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER rn <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool. Dia. of Well Excavation �t <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> V, 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 s * <br /> Type of Pump -7--4 , ` H.P. u <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done _ a,d vt 6Lj 01 ,4 <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 kno edg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND A FINAL INSPECTION. <br /> SIGNED c.r ITLEr . <br /> DRAW P ON REVERSE SIDE <br /> L =J <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY J DATE J�- !V — 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />