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•.......... <br /> `1+ <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT 3-7 <br /> FOE'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S=3dSlcl <br /> I� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> j�o..Uelip is te) � <br /> Application is hereby made e S He 1 Dist or a permit to construct <br /> and/or instal the work h ei d ri. a in compliance with San Joaquin <br /> County Ordinance No. .,, _._. thy' S n Jo uin Loc 1 Health Di tri t. <br /> JOB ADDRESS/LO ATI [ ` C <br /> Owner's Name C Phone ' <br /> Address City <br /> Contractor's Name License #c home � -�3 # <br /> TYPE OF WORK (Check) : NEW WELL/' DEEPEN `47 RECONDITION � DESTRUCTION 7 <br /> PUMP INST TION / / PUMP REPAIR -/-7-pump REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE <br /> HSPOOFIT PRIVY ' <br /> SEWAGE DIS SATFIELD L/S PIT OTHER <br /> _- PROPERTY LINE �- PRIVA�STIC WELLI; 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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation, I Gravel Pack . Depth of Grout Seal <br /> Cathodic Pr_otect_i_ on . .Rotary - ;Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Sur ace Seal Installed B : , <br /> PUMP INSTALLATION- Contractor <br /> Type of Pump B.P. <br /> f <br /> PUMP REPLACEMENT /° State Work Done <br /> d1i <br /> PUMP 'REPAIR: / State�Work -Done - „ <br /> DESTRUCTION OF WELL: Well Diameter Ap ra ate Dep h " <br /> Describe Material and Procedure <br /> I hereby agree to complywith all laws and regulations of the San Joaquin Lo.cal 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 /> informaton_is ,true to the,be of. my knowledge and belief. I WILL FORA GROUT INSPECTION <br /> PRIOR TO GRO NG D VIN SP IOV. <br /> SIGNED '". TITLE <br /> 7_77- (DRA T PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I' <br />� APPLICATION ACCEPTED 3Y DATE �^ <br /> 4 ADDITIONAL COMMENTS: Pll _. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 4 INSPECTION BY DATE a ,g' INSPECTION BY DATE <br /> E H 1426 Rev. 1--741 2M..- <br />