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SAN JOAQUIN LOCAL HEALTH DISTRICT _ m <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7F- <br /> THIS <br /> FTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 4 ' (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 anA the Rules and Regulatis of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � � � <br /> _E' �iE� n� �IVt?OiN�Rd _S'_ II�N`T+EC R�CENSUS TRACT <br /> E 4 <br /> ' M g Phone <br /> Owner's Name <br /> Addressl <br /> Q0 �KCREEK fig. City i7-QeK 7'0A1 _ <br /> Contractor's Name Allmp .License # Phone ' <br /> �i y <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENS/_/ RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> n <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES PTT PRIVY <br /> SEWAGE ;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER fl <br /> _PROPER-TY LINE---PRIVATE-DOMES TIC-WELL—TPUBL'IC-DOME STI-C-WELL <br /> INTENDED USE TYPE OF(WELL S Av0 - ., Vf CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation _ /6 ff <br /> >C _ Domestic/private_,._., 4_-_:..Drilled­ —Dia-.---of--Well Casing------- —t! <br /> Domestic/public i Driven Gauge of Casing 42 - __ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection C Rotary ,-�--.-----Type-of Grout _,oAhmE <br /> Disposal Other, Other Information° ...— <br /> GeophysicalX � ,Surface Seal Installed BY: &0 <br /> PUMP INSTALLATION: Contractor ow <br /> Type of Pump ,LF s H.P. <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP :REPAIR: <br /> State Work Done <br /> DES.TRUC_TION 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 'constru�tion. 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 above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G ANDIA F ! INSPEC ON. <br /> SIGNED TITLE <br /> I (DRAW -PLOT PLAN ON REVERSE`SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY - 11 DATE 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 7 <br /> �= E H 1426 Rev. 1-74 <br /> : 1177. .. 20� <br />