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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cali. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP ERMIT r No j�6 lc <br /> THIS PERMIT EXPIRES 1 YEAR FROM 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. Rules and Regulations of the San Joaquin Local Health .District. <br /> I <br /> JOB ADDRESS/LOCATION D t4l CENSUS TRACT <br /> Owner's Name LO Phone 4,1!? -7/ <br /> Address 0 !.f/' G. 4 S /ZD City <br /> Contractor's Name <br /> -- / 5 /JG �/ � License #a'�S7�f Phone 4/44, 3 <br />-TYPE-=0F WORK�(Cherk)-:—NEW-WELL`/7`-'DEEPEN--/7 RECONDITION-/7—DESTRUCTION 77 <br /> PUMP INSTALLATION' / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private, Drilled Dia. of Well Casing <br /> M1 <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I <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 Gv13 H.P. <br /> PUMP REPLACEMENT: . State Work Done <br /> PUMPIREPAIR: State Work .Done <br /> a <br /> bESiTRUCTION 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-best,of- my..knowledge and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (D PLO LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -/�''7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE. --_5C X76 <br /> E H 1426 Boer- I-74 <br />