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01 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209;} 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No." �f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/L-/ _7, <br /> 35 evk?u- :z))op9 � ' (Complete In Triplicate) t-7'?,— ,5&0--0. <br /> Application-'is`hereby'"made to the San Joaquin Local Health District far a permit. to Xll-,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 /> AB DRESS/LOCATIO 733' j5 e F s, CENSUS TRACT <br /> Owner's Name Phone eG2- 7Ef <br />{ Addresr l� S'/ . City .5X&cA7'a-&Z <br /> Contractor's Name o g Ag ct t Pe, License #z_9Yytf-:r,-Phone Z2�j 3 rjE <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION / ``/ DESTRUCTION /-7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 1"r-. SEWER LINEStial t-- PIT PRIVY <br /> SEWAGE BISPOSAL FIELD /gT CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINFM PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial e.---Cable Tool Dia, of Well-. Excavation r a� <br /> Domestic/private Drilled Dia. of Well Casing;% <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal s'p <br /> Cathodic Protection Rotary Type of Grout ,_.__. _. th <br /> Disposal Other Other Information _ <br /> Geophysical _ Surface Seal Installed B 1Za :r-S. <br /> PUMP INSTALLATION Contract.or'.' i <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / V State Work Done <br /> PUMP .REPAIR: / / State—Work Done ; <br /> DES-TRUCTION OF WELL' <br /> c Well Diameter ti Approximate-Depth._' - ._Z= <br /> - ►� Describe 'Material. and Procedure <br /> Y hereby agree to comply1with all laws and regulations of the San Joaquin Local Health Districti� <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS I <br /> after completion of my work on arnew well,.' I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT; of the well,and notify them before- putting thewell in use.. . The above <br /> information is true• .to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIQN <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. Es� oq. <br /> SIGNED TITLE j <br /> t (DRAW 'PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4g., <br /> APPLICATION ACCEPTED' BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE XI GROUT INSPECTION € PHASE III/FINAL INSPECTION <br /> ZNSPECTIONvBY DATE - INSPECTION BY,_ DATE <br /> 2M <br /> E H 1426 Rev. . 1-.7.4 h <br />