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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,, FFICE US :� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6w '7b <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fot 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 .f' . . i CENSUS TRACT <br /> Owner's Name � a u .e1�' .�t�[1 _., Phone <br /> Address ?-a . j d ? City.- 'y�D <br /> Contractor's Name ��. ) License / - hd hone F ,��,�' <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/_T RECONDITION /7 DESTRUCTION /7 j <br /> PUMP INSTALLATION ,/ / PUMP REPAIR &7 PUMP REPLACEMENT f_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY Q <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 J <br /> �A Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 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 B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. , <br /> PUMP REPLACEMENT: . J / State Work Done <br /> PUMP .REPAIR: /)r/ State Work Done ,y , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth R <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 Loeal 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 aknowledge and -belief. I WILL CALL FORA GROUT NSPRCTION <br /> PRIOR TO GROUTING AND A FINAL IN E <br /> SIGNE -.-TITLE <br /> T PLAN .ON VERSE SIDE <br /> , FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -Z 'g- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PE INAL INSPECTION <br /> INSPECTION BY `L——DATE- _ INSPECTIO DATE -S <br /> CT <br /> E 11 1426 <br />