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' I SAN JQAQUIN LOCAL HEALTH DISTRICT <br /> 1i;Z OFFICE USE: 1601�E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zia <br /> i 6 <br /> THIS PERMIT EXPIRES1 YEAR FROM DATE ISSUED Date Issued cf� <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 Health District. <br /> i' jj / � <br /> JOB ADDRESS/LOCATION.,. �.2 G./n//✓ o� Lo � CENSUS TRACT <br /> Owner's Name L .. PhoneZ�- <br /> Address �l�" Z' /✓. �i�./il/ L City <br /> Contractor,'�s Name _.-,._._License #=_ — -Phone3�a� <br /> F <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_T RECONDITION /-7 DESTRUCTION /7 <br /> ` PUMP INSTALLATION / I PUMP$ REPAIR / / PUMA.' REPLACEMENT <br /> Other <br /> r. 1, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SAGE-�DISPOSAL.FIELD ( CESSPOOL/SEEPAGE PIT OTHER -` <br /> PROPERTY LINE- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL q� <br /> INTENDED USE I TYPE OF WELL a CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> a( 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 1 'Surface <br /> DSeal <br /> �lInstalled By: _ <br /> PUMP INSTALLATION: Contractor ,�! JY✓f� c1�N /GSM!~ _ <br /> Type of Pump �L)43 __ H.P. r� <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> 4 <br /> PUMP 'REPAIR• t /� State Work <br /> ,?ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> 4 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-best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND F AL I ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I DATE <br />' APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> ► PHASE II ROUT INSPECTION PHASE III/F, NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE z _ fs <br /> 't E H 1426 Rev. .1-74 I-74 2M _ <br />