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SAN JOAQUIN LOCAL HEALTH DISTRIr- <br /> FOR OFFICE USE: 1 T_ E. Hazelton Ave. , Stockton, C`if. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-(f 6V <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S / ��/W 1G�1 CENSUS TRACT <br /> Owner's Name It (3tGfirr Phone h✓� �r'r� �i <br /> Address City A� <br /> c <br /> Contractor's Name_ln� J License A��` /F- 7�Phone <br /> TYPE OF WORK (Check) : NEW WELL AT DEEPEN /_' RECONDITION /_7 DESTRUCTION /_7 (0 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 Q <br /> Other / / G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO& FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _' Domestic/private Drilled Dia. of Well Casing E, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection }c Rotary Type of Grout <br /> �a <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor >2�e C ft <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth J <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR PE PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G2 . S DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE, I ' ROUT INSPECTION PHASE IFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE — <br /> E H 1426 Rev. 1-74 1-74 2M <br />