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f <br /> SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> { <br /> OR OFFICE USE: + 1601 E. Hazelton Ave. , Stockton, Calif. ; <br /> i Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l- <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 Josquit <br /> County Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /� CENSUS TRACT <br /> Owner°s Name ° I Phone . <br /> ,Address Zv4AAJ tJ) City Ga�"`� G. <br /> Contractor's Name WLTA P -y .& License #.2ftjjq Phone '5 <br /> l <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT /_7 <br /> Other ! / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ZPIT 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 /> _ <br /> Industrial � Cable Tool Dia. of Well Excavation �:2 U <br /> O 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 ' r t _ Surface Seal Installed BY: <br /> I PUMP INSTALLATION: Contr1actor <br /> Type' of Pump _ _ H.P. <br /> PUMP REPLACEMENT: <br /> / / ' State Work Done •� <br /> PUMP iREPAIR: /7 State-Work Doh&—' <br /> ESESTRUCTION_ OF WELL: Well Diameter _ ..�. �rt � 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 theta before putting.-the well in use.. The above <br /> informatio t ue to the, best of. my YAiQwledge and belief.Y :I°-WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO qA0U1I4 AND A FINAL INSPECTI <br /> SIGNED to TITLE <br /> (DRALOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE //j,-)6 <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT: INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B __. DATE j t-_S0--1 G_ <br /> 1 ,.�.E H 3426 Rev. 1-74 ... _ .. <br /> 1-74 2M <br />