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to gyp + �'� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--678 . . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ?—,4-21' <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 A,. G ,� o�s- p c� «;� , CENSUS TRACT <br /> Owner's Name h Phone <br /> Address R0, ! City <br /> �e1 <br /> Contractor's Name License # / ,L Phone (A" <br /> TYPE OF WORK (Check): NEW WELL 'f / DEEPEN '/ RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR '.f PUMP REPLACEMENT <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 /> INTENDED USE TYPE OF WELLCONSTRUCTION .SPECIFICATIONS <br /> — — Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 h <br /> Geophysical Surface Seal Installed By- <br /> PUMP <br /> :PUMP INSTALLATIONo. Contractor � <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: . / ] State Work Done I <br /> FUMP :REPAIR: ;. / State Work Done <br /> DESTRUCTION 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 /> WELL DRILLERS REPORT of the well and notify them beip.r..e' putting the-.well- in-use,. The above <br /> information is true to the-hest.o€ my..tF"now d bel f. <br /> PRIOR TO I `WILL CALL FOR A GROUT INSPECTION <br /> ROU ..NG AND, FINAL INSP <br /> SIGNED , Q e $61 <br /> (D P PLXN ON REVER SIDE <br /> DEPARTMENT"USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY u DATE ' ?__5 ,.5_ <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT I PECTION PHA N NSPECTION <br /> INSPECTION BY DATE INSPECTION BYATE 7 — . <br /> F. FI 1G7Fi n,,.,.- 1_'74 <br />