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4?1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �N�'`� = <br /> 'FFICE USE: E. Hazelton Ave e, Stockton, Calif. j r - A�o�9 <br /> Telephone:, (209) 466-6781 f/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ <br /> ' (Complete In Triplicate) <br /> Zppan <br /> lication is Aereby made to the San Joaquin Local Health District for a permit to constructconstruct <br /> install thework 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 74 OoW ENSUS TRACT <br /> Owner's Name �[ � � �L Phone ' ��`��/�y/ <br /> Address� 'City , -yicelvAl--- <br /> Contractor's Name T/I�f" "� �y �I �C U ' .License�� �4/43 Phane <br /> TYPE OF WORK (Check) :� `NEW6WELL DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> -PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 i <br /> ` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ _ OTHER <br /> t PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL' <br /> INTENDED U5E TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation &" <br /> Domestic/private _ _) Drilled �, Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout anv _ + <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. `" y+ " <br /> PUMP- .REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: a 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 wellxand notify them before putting the..well in use. The above <br /> in rmatian is the best'�of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION k <br /> PRIOR 0 GROUT NG MPECTION. <br /> SI ., TITLE0-Ci <br /> (DRAW PLOT PLAN ON'�REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I OAIVILO_;�APPLICATION ACCEPTED BsJ, DATES/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION > PHASE III/,FINAL INSPECTION, <br /> INSPECTION BY r. ' DATE -- Z INSPECTION BY DATE - 7 <br /> E H 1426 Rev. 1-74 <br /> 117.7 - 2M - <br />