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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF OFFICE USE: 1607 Hazelton Ave. , Stockton, Cal . <br /> ' i Telephone : (209) 466-6781 V <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued Z::�-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 :ell 4�2�} �,� E �,,. <br /> '� CENSUS TRACT <br /> .Owner's Name 11�__ , _ <br /> Phone 1..3/�- <br /> Address `� y <br /> City �.. � _ <br /> Contractor's Name /� � ; License (e�f yT + <br /> 7 Phone Y kKi� <br /> TYPE OF WORK (Check) : NEW WELL _ _/ / DESTRUCTION /_7 <br /> • � DEEPEN/ / RECONDITION <br /> PUMP INSTALLATION 4 PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PR <br /> PROPERTY LINE) IVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia., of Well Excavation <br /> 2<, Domestic/private Drilled /4* <br /> Domestic/public Dia, of Well Casing <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection Rotary <br /> Type of Grout <br /> Disposal <br /> Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> zlrz c�.c <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump /r, H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP -REPAIR: / / State. Work Done <br /> DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i. <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 the well and notify diem before putting the -well in use. The above <br /> information is t _.e_..to.__the-best of my..knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO R V G,AND A I tsPE ON. <br /> SIGNED -� TITLE f <br /> D W PL T PLAN ON RE FRSE SIDE is <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS. - DATE 6 <br /> GROUT INSPECTIO PHAS Ii /FINAL INSPECTION <br /> INSPECTION B DATE �2 8 INSPECTION BY G-�- DATE <br /> E H 1426Rev. 1-7417/Ab <br /> i < 3/76 2M <br />