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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OR,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. GS <br /> ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ! k.I (Complete In Triplicate) <br /> t 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin .Local Health District. <br /> -.'.JOB ADDRESS/LOCATION p CENSUS TRACT <br /> x <br /> Owner's Name 6Y In Q Phone Z <br /> ro <br /> Address �- 6L/0 9 ,AL ''JFLApofAaQ _ CityS-7-OC-LIMN <br /> Contractor's Name License #222 Phone�yg-�SJrI <br /> k <br /> is <br /> k: TYPE OF WORK (Check) : NEW WELL�Z�_=--DEEPEN:/�/`}RECONDITION--/'=° DESTRUCTION /? 4 � <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 {li <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD xCESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY' LINE - PRIVATE=WRESTI•C :WELL PUBLIC'DOMESTIC WELL <br /> I 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 -X0--5?iven Gauge of Casing <br /> Irrigation - "'`fi Gravel Pack Depth of Grout Se4A <br /> Cathodic Protection x Rotary Type of Grout p <br /> ,Disposal Other Other Informationl-j <br /> Geophysical ' Surface Seal Installed By: , <br /> fF <br /> PUMP INSTALLATION: Contractor y <br /> .. <br /> Type of Pump t: H.P. <br /> { PUMP REPLACEMENT: / / Sta_te.'Work Done <br /> a���� <br /> PUMP REPAIR:` / /.. State Work Done <br /> roximate Depth <br /> ;. DES•TRUCTTOI3 OFA'°°WELL: Well- Diameter A PP P <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 "construct16n. Within FIFTEEN DA S <br /> after completion of my work on a new well, I will furnish the San, Joaquin Local Health District g <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> .r information is true to thelbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> s PRIOR TO GRQWING AVD NAL IN ECTION. <br /> SIGNED V &t TITLE`_ <br /> (DRAW PLOT PLAN- ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY TE '`S-1$ <br /> ADDITIONAL COMMENTS: ls1► � ' <br /> PHASE II GROUT INS ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE J•/ T INSPECTION BY f% DATE <br /> s; <br /> E H 1426 Rev. 1-74 1177 _. ' <br />