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AN JOAQUIN LOCAL HEALTH DIS M CT --` <br /> FOI}rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �1 <br /> Telephone: (209) 466-6781 7 S- �16 n <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-T-- 7`?t" <br /> THIS PERMIT.iEXPIRES 1 YEAR FAOM,.D,dE ISSUED Date Issued 3- s-7 <br /> f (Complete In Triplicate) <br /> Application is hereby mad io, the San Joaquin Local Health District for a permit to construct <br /> and/or .install the work rein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION " i <br /> ` ; CENSUS TRACT <br /> Owner r s Name10 Phone7b*7 - 2 6 3 - 3 <br /> 010 <br /> Address <br /> City <br /> Contractor's Name Lic se # Phone i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/_7 RECONDITION /_7 DESTRUCTION <br /> PUMP IN ST LATION / PUMP REPAIR /�PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC YANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FjELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL "PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia, of Well Excavation /0 '1 <br /> _ Domestic/private i Drilled Dia. of Well Casing rr � <br /> _= x Domestic/public F Driven Gauge of Casing <br /> Irrigation 1. -Gravel Pack Depth of Grout Seal { <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal , , Other Other Information <br /> Geophysical' 4 <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump e H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> -- Z_7.. Sta e_Work Done . .. .._. -. . <br /> ESJRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> K <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 of my .knowledge and belief. I WILL 'CALL FOR A �GROUT INSPECTION <br /> PRIOR TO G UTING AND INAL INSPECTION; <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FORT USE ONLY <br /> PHASE I -- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: 1"e-A-, DATE � <br /> P SE GROUT INSPECTION PHAS . <br /> I FINAL INSPEC ION <br /> INSPECTION BY DATE 5',2,2;']s INSPECTION BY DATE Q, <br /> E H 1426 Rev. I-74 7-74 9M # <br />