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r SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> ) O1e'OrFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL C09ST tUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued _L,21-2 <br /> (Complete In .Triplicate) <br /> Application is hereby made to the San Joaquin Local, Health District for a peL-Mit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 186 ad the, Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 0 o CENSUS TRACT <br /> OwnerQs Name. rr.C Si Phone <br /> Address <br /> City -�, <br /> Contractor's NaiAe +S N-o a C License # qqG rz. Phone jil?- 3 Y5(e <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/-7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION /R/ PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other J% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER { <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor A) 4-S <br /> Type of Pump __ S�w r g_ „6 I _.._„,... H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: /? State Work Done - _ <br /> PESTRUCTION 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 shove <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 .Q, Lj TITLE . r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I •). <br /> APPLICATION ACCEPTED BY r DATE /7-,7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III N INSPECTIO <br /> INSPECTION BY DATE INSPECTION <br /> - i • <br /> ;µE H 1426 Rev. 1-74 1-.74 2M <br />