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V1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OF ICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR -WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S_- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- Date Issued Z-/__,_7F <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..Heelth District. <br /> JOB ADDRESS/LOCATIONx� <br /> CENSUS TRACT'' <br /> Owner's Name LIP A*;1 61`e Phone <br /> Address 4-07 City ' <br /> Contractor's Name License # Phone YV-,i 76 ]� <br /> IV <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/-7 'RECONDITION 1-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR -/-7 PUMP REPLACEMENT 17 <br /> Other /_7 <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 t� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP ,�TRr / State Work Done A/altj _ <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 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,bestgfmy knowledg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL N �^ <br /> TITLE L- Irl". <br /> / (DRA POT PLAN ON IWVERSE SIDE) -' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , j / 7 ?LS <br /> ADDITIONAL COMMENTS: 14�2 r <br /> PRASE II GROUT INSPECTION INSPECTIOX <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r` 4/_75 � _ <br />