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SAT AQUIN LOCAL HEALTH DISTRICT <br /> %n OFFICE USE: 1/ 1601 E;-[;azelton Ave. , Stockton, CaliL. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' 7SS��4� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ <br /> (Complete In Triplicate) <br /> -lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> !/or install the work herein described. This application is made in compliance with San Joaquin <br /> ity Ordinance No. 1862 and Lhe Rules and Regulations of the San Joaquin Local Health District. <br /> i ADDRESS/LOCATION X77 <br /> '- n�O CENSUS TRACT ' <br /> .r°s Name <br /> Phone - 7 2y� <br /> tress LAo// EI <br /> .-ractor's Name <br /> License # Phone <br /> OF WORT: (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMEXT /7 <br /> Other <br /> n;ANCE 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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ^ Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal �J <br /> _ Cathodic Protection Rotary Type of Grout " <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ' INSTALLATION: Contractor \\ <br /> �C3e <br /> Type of Pump H.P. <br /> REPLACEMENT: / / State Work Done <br /> .REPAIR: / / State Work Done <br /> 'RUCTION OF WELL: Well Diameter zz Approximate Depth _ <br /> Describe Material and Procedure <br /> reby agree to comply with all laws and regulations of the San Joaquin Local Health District { <br /> _the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .er completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ,rmation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -R TO GRO 1 NG ANP A FIN rP ION. <br /> ;NED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> SE I i <br /> KATION ACCEPTED BY. DATE f� <br /> _.TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIk/FINAL INSPECTION <br /> ECTION BY DATE INSPECTION BY a,� 4--e DATE ;_ L <br /> I <br /> E H 1426 Rev. 1-7G - <br />