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L/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /I/" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7-}f7S) ` <br /> I <br /> THIS" PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7) 3 <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. CENSUS TRACT <br /> e <br /> Phone <br /> Owner's Name j:••. _— <br />,,Address — f?�Z�r�ot SS Z/�7 , ,1�n l" ►r �� -- City � L� <br /> T <br /> Contractor's Named/. cls✓ _ License Phone <br /> t <br /> TYPE OF WORK (Check) NEW WELL -?/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 ' <br /> PUMP. INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> 'may Other'-/ <br /> DISTANCE.TO NEAREST:.. SEPTIC TANK _ _SEWER LINES PIT PRIVY 1 <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 /> Domestid/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 /> Geophys-kcal '- -"� "''°""""'� Surface Seal`Installe`dT By: _�_ .�I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done rr <br /> PUMP .REPAIR: / / State Work Done <br /> �i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 />.. 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 FORA GROUT INSPECTION <br />,PRIOR TO GROU G AND A F,N L INSPECTION. <br /> SIGNED TITLE <br /> - (DRAW PLOT PLAN ON REVERSE SID2) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> isAPPLICATION ACCEPTED BY DATE " <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GR ,UT INSPECTION PHASf IIXO INAL INSPECTIO <br /> INSPECTION -BY W DATE INSPECTION B JDATE <br />