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'V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT € <br /> -To—r,-"OFFICE USE: ' ` 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> II Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT, EXPIRES 1 YEAR FROM DATE ISSUED Date ,IssuedZ$' <br /> (complete In Triplicate). <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joagl �tni <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `SlMi O�ixi�Iy�S` CENSUS TRACT <br /> Owner's Name Phone <br /> f <br /> Address <br /> Contractor's Name: I� t License # '32-/Z-!5 hone 63Z-713 <br /> .�M <br /> U� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /�/ RECONDITION 1-7 DESTRUCTION /7 V ' <br /> PUMP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT /7 V ; <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE.= PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> 1/r� <br /> .Irrigation Gravel Pack Depth of Grout Seal <br /> . Cathodic Protection 1-1 Rotary'. Type of Grout <br /> Dispasa Other Other Information <br /> Geophysical J� Surface Seal Installed By: <br />( PUMP INSTALLATION: Contractor <br /> Type of Pumps .H.P. . <br /> PUMP REPLACEMENT: h j State Work Done <br /> PUMP .REPAIR: A$ / State Work Done <br />; DES•TRUCTION OF WELL: Well Diameter } Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to comply; with all laws and .regulations ofmthd San Joaquin Local Health District <br />; and the State of California-;pertaining to or regulating well'-construction. Within FIFTEEN DAYS <br /> after completion,af my work; on a new well, I will furnish the San Joaquin,'Local Health District a <br /> WELL DRILLERS-REPORT of ':' ': well and notify them before putting the..well in use. The atiove <br />', information is true to the best of- my.kno,41edge and belief. I WILL CALL FOR A GROUT INSPECTION <br />`PRIOR TO ING AND A FINAL INSPECTION. <br /> SIGNED TITLE _ <br /> Il (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I J7 57 <br />.APPLICATION ACCEPTED BY DATE G , <br /> ADDITIONAL COMMENTS: .t <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE- 8-- - 79_ <br /> �E H 1426 Rev.' 1--:7 <br />