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y � ? <br /> V/1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTFO&:OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z& <br /> r <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 RSI Sa�xd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �fCENSUS TRACT <br /> Owner°s NameV S T (,,LC TIC Phone f' - 7�Q o <br /> Address City J l 110-le o f <br /> C <br /> /� J c <br /> Contractor's Name L.�1` WELL EO 0,1 PLicense #_7L(V t)2.-Phone L142-43 ; <br /> TYPE OF WORK (Check): ,NEW- WELL o f <br /> /DEEPEN '/_7 RECONDITION /7 DESTRUCTION f <br /> /PUMP INST TION / / FUMP REPAIR / PUMP REPLACEMENT /� <br /> 1 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 /> INTENDER USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable Tool Dia. of Well Excavation j611 <br /> Domestic/private Drilled c Dia: of Well Casing <br /> Domestic/public Driven Gauge of Casing 12 ' <br /> Irrigation Gravef Pack Depth of Grout Seal <br /> Cathodic Protection Rotary -- Type of Grout ' -�! EMlj 10177_ " <br /> Disposal ' Other Other Infbrmation � <br /> Geophysical Surface Seal Installed By: 0T4G % t <br /> PUMP INSTALLATION: Contractor f� 1✓�1. Lk I PH1,0I <br /> Type of Pump t t3}4 f"3 L ._.� H.P. <br /> PUMP REPLACEMENT: %// State Work Done <br /> PUNIl? !REPAIR: /? State Work Done <br /> SESdRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulatioine 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-best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO U tNG.AND A FINAL INSPECTION. 60"14G <br /> � <br /> SIGNED TITLE i.o0l�4(1'TT�j _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> .`ems�. ......_ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BYDATE �S <br /> H 1426 Rev. 1-74 <br /> 1_74 2M <br />