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r <br /> h x SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> V F10E USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRICTION OR PUMP PERMIT Permit No,7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z/�/ <br /> (Complete In Triplicate) <br /> 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 Joaquin <br /> County Ordinance No. 1862 and the Rules annd/d��Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONe-oA-Wo f'" i - CENSUS TRACT <br /> Owner's Name + �l.� k,�op ' Phone <br /> Address cso Cityd <br /> Contractor's Name Q � �r License # & ij'Phone 7- 7L7� <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /-7 RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTLATION REPAIR Z/ PUMP REPLACEMENT /7 <br /> AL <br /> other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS %5 <br /> Industrial Cable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> >I~ 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 (ZI�4m).11 <br /> Type of Pump H.P. d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: /7 State Work Done - s. <br /> ES•TRUCTION 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 thew before putting the, well in use. The above <br /> information is true to the best of.,,my owledgebelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL INSPE IO <br /> SIGNED + ITLE <br /> W PL T - 2:nt <br /> PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> 1 E H 1426 Rev. .1-74 1-74 2M r <br />