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w Seg., JOAQUIN LOCAL HEALTH DISTRICT <br /> F'bF�-OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s- 61Z710 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,2_ y1_7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun 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 /> JOB ADDRESS/LOCATION l ,'/t ,S kit/�rc�,�,n�- ' CENSUS TRACT <br /> Owner's Name "x >��: r .� ;fi Phone <br /> Address - 4Z a,. G// t�G�t rJyoGQ ��� City <br /> Contractor's Name ��D W ;r'�,: ° ► _; "�* License # 3 7Lj__Phone <br /> VI <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR IZ-7 PUMP REPLACEMENT /_7 <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 /> � i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \�\ ' <br /> Industrial Cable Tool Dia. of Well Excavation \' <br /> Domestic/private Drilled Dia. of Well Casing c�' I <br /> Domestic/public Driven Gauge of Casing <br /> 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 <br /> Type of Pump L H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done � <br /> PUMP .REPAIR: /}</ State Work Done f S �'�� /; � f <br /> 11 <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 /> n1ELL 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.bglief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GRO NG AND A FINAL INSPECTION. <br /> SIGNEDj A <br /> A.,c ITLEir a� ` <br /> DRAW L T PLAIT ON REV SE SIDE) <br />'RASE I FOR DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I <br /> E H 1426 Rev. 1-74 <br />