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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> # FQTQ :FILE USE: 16Q1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�7-07/W A� <br /> THIS PERMIT EX.PIRES,l YEAR FROM DATE 'ISSUED. Date Issued_ 3 <br /> (Complete In Triplicate) "" <br /> Application ie 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> aas6z <br /> JOB ADDRESS/LOCATION /tI, 'l - t CENSUS TRACT <br /> Owner'sName Phone ' &22/ <br /> i <br /> Address City ' . <br /> Contractor's Name License # `aD Phone <br /> TYPE OF'WORK (Check): . NEW WELL DEEPEN '/'7 RECONDITION /� DESTRUCTiQN <br /> PUMP INSTALLATION j / PUMP REPAIR -/-7—PUMP <br /> REPLACEMENT <br /> Other!/—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK a3jy+ SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' ':_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial E� Cable Tool Dia. of Well Excavation s/ <br /> Domestic/private Drilled Dia. of Well Casing 17 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigationlk- <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �r <br /> Disposal Other Other Information ' <br /> Geophysical ..� Fn Surface Seal Installed 'Bv: <br /> , . <br /> PUMP INSTALLATION: Contractor # Y '-.3 <br /> Type of Pump - H.P. <br /> _ x <br /> PUMP: REPLACEMENT: - /7 State Work Done <br /> PLW .REPAIR: _ - <br /> /- State Work Done 4 . <br />€ 4.DESTRUCTION 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 weil "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new .well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before `putting. the..wel1. in.use.... .The above <br /> information is true to the-best-of my knowledge and belief. I WILL CALL FOR" A GROUT INSPECTION <br />� PRIOR .TO G OUTING AND FINAL` NSPECTION. <br /> SIGNED ' <br /> TITLE <br /> RAWr POT PLAN ON VERSE SIDE <br /> R ARTMF T USE ONLY i <br /> PHASE I <br />� APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: E . <br /> PHASE II GROUT INSPECTION <br /> PHASE III F NAI, IN`JPECTION <br /> INSPECTION BY. aADATE - INSPECTION 'BY E. <br /> E H 1426 Rev. 1-74 <br />