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6 is SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFIC rUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466y-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereb�/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/LOCATIOM a + VA r CENSUS TRACT I(S—C"R9-03 <br /> Owner's Name Phone (� <br /> Address ` �r^�/ V , City <br /> Contractor's Name �►�if , License # / Phone1,.' _7� 7Z <br /> 4L 0k <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 W <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /- CIP <br /> Other / / <br /> 17) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing 4 '1 <br /> Domestic/public Driven Gauge of Casing 4 <br /> ye Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information _ s <br /> Geophysical Surface_Seal Installed By: ( �� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump —0 '" 0 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: State Work Done y So r <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 <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 y know •e-dia d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL INSC IO . n <br /> SIGNED TITLE <br /> XDRAW PLOT PLAN ONMEVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY L%/ DATE <br /> ADDITIONAL COMMENTS: «, <br /> PHASE II GPyOUT I PECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .01 <br /> E H 1426 Rev. 1--74 ' 117.7 _ 2M <br />