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�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFr OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T7- 7 7G.J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;Zp_26 <br /> # (Complete In Triplicate) t" <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 V1 CENSUS TRACT ' . <br /> � �' <br /> Owner's Name I �f Phone27 <br /> Address 11- VE <br /> City S ld/U <br /> Contractor's Name � 7 /�/ _ l�/! � '$ jJ.'l P C(,�License # Phone J4�Z-3 Z. <br /> TYPE OF WORK (Check): - NEW WELL DEEPEN/7 RECONDITION _ S <br /> �T. /-7DE DESTRUCTION f_7 <br /> , <br /> PUMP INSTALLATION. /� PUMP,REPAIR /� PUMP REPLACEMENT T <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER 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 , <br /> Domestic/publicrir3ven Gauge of Casing '� k <br /> Irrigation Gravel Pack Depth of;Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ . Other Other Information v <br /> Geophysical'' Surface Seal Installed 'B — <br /> PUMP INSTALLATION: Contractor , ; <br /> Type .of Pump H.P. <br /> h <br /> PUMP REPLACEMENT /�./ State Work Done <br /> PUMP �REPAIR: i. <br /> State Work Done t <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure ._r <br /> I hereby agree tocomply r�ith all laws and' iegu1at36ns of the San Joaquin Local Health District <br /> and the State-bf'Cakifoi is pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well,-1- will furnish the San Joaquin Local Health District a <br /> WELL,.,DRILLERS REPORT of the well. and notify them before putting. the..we11. in.use.... .The above <br /> information is true the-best-of- my. knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO G UTING Ft INSPECTION. <br /> SIGNE� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCE B S�HM 1 DATE LO <br /> ADDITIONAL COMMENTS.: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION { <br /> INSPECTION BY DATE INSPECTION BY DATE .. <br /> E H 1426 Rev. 1--74 i l./7� 9M '� <br />