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SAN JOAQUIN LOCAL HEALTH DISTRICT - ' <br /> FO-9 OFFICE USE: (/ 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;a-S 9l W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7Y ._3 k7,00 <br /> Date Issued $ 7SG <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 /> JOB ADD HHS/LOCATION. L8 Gk L ��f <br /> �" �'� CENSUS TRACT <br /> Owner's Name . 2-- Phone <br /> Address City <br /> r <br /> Contractor's Name YtZ? l f�A,l-ter/ f License 95?:� Phoneme -- <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other /% "— <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OfHER �- <br /> PROPERTY LINE PRIVATE DOMESTIC WELL/.d—Od`PUBLIC DOMESTIC WELL—b -f-- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / 'Z <br /> Domestic/private Drilled Dia. of Well Casing <br /> Cr <br /> Domestic/public Driven Gauge of Casing Z.. <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type .of Grout <br /> Disposal Other Other-Informatio�' r <br /> Geophysical Surface Seal Installed BY: _614. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> Pit.!.REPAIR; /? State Work Done <br /> ES•TRUCTON OF WELL: Well Diameter Approximate Depth j <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-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT <br /> SIGNED ITLE <br /> PL T P ON REVERSE SIDE <br /> t _r _ _ FOR D ARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,d7'y/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE III FINAL NSPECTIObf <br /> INSPECTION BY ; DATE INSPECTION- BY DATE ' <br /> E H 1426 Rev. 1-74 1-74 2M <br />