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_ .------ <br />�. __.. ::;• ,... r w >. `. 4 -- fir" <br /> SAX JOA(}Ulir'" CAL HEALTH DxSTRICT <br /> F , <br /> FOR;QFFICE USE: 1601 E. Hazeltbn.Ave' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,� _ 7S'&J1 <br /> THIS PERMIT EXPIRES 1,-SEAR FROM DATE ISSUED Date Issued f-.2-0-7q- <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 -and /Regulations of the San OJoaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner'a Name Phone-'Y-164 C� c <br /> Address -'Lam✓ ,� •� 1 City �C/l! <br /> Contractor's Name <br /> 'L 7-7-7 <br /> License" ' � Phond"Z <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_7 /_7DESTRUCTION /"j <br /> - <br /> _/ RECO � <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—PUMP REPLACEMENT 17Other / / <br /> r � <br /> DISTANCE TO NEAREST: SEPTIC TANKA00 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 SPECIFICATION <br /> Industrial Cable Tool Dia. of Well Excavation f1 s <br /> Domestic/private Drilled Dia, of Well Casing _11 <br /> Domestic/public Driven Gauge of Casing ev <br /> Irrigation Gravel Pack Depth of Grout Seal o <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface_Seal Installed. By: <br /> PUMP INSTALLATION: Contractor ;I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: --- /7 State Work-Done <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 j <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..weli 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED 'm . TITLE y <br /> (DRAW PLOT PLAN ON REVERSE SIDE ,._. - -- _. 1 <br /> FOR DEPARTMENT USE ONLY - - <br /> PHASE I <br /> APPLICATION ACCEPTED BY9 ". <br /> - 'DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 2 f <br /> i E H 1426 Rev. 1-74 <br />