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SAN JOAQUIN LOCAL HEALTH DISTRICT -' - <br /> FOR OFFICE USE: 7 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 X21,-�8' <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 /> Count Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> County IdJI-TA O 9 <br /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Phone <br /> F41 <br /> �. <br /> Owner's Name e <br /> t city <br /> Address <br /> Contractor's Name ' <br /> h License #,P �JPhone <br /> TYPE OF WORK (Check) :.,_..NEW_WELL ._.,�.DEEP.EN,-/./---RECONDITI.O _ /%y_DES�RiTGTZON�I?---�----�- <br /> PUMP INS LATION �/�./ PUMP--REPAIR-,/ I� PUMPS REPLACEMENT_.^I�T <br /> 0thef _/ I s. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWLINES IT PRIVY <br /> ER R <br /> I� SEWAGE DISPOSAL FIELD CESSFOPI OTHER <br />! PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> }` Lurm <br /> INTENDED USE TYPE OF W - -CONSTRUCTION SPECIFICATIONS <br /> Industrial a 1e Tool Dia. of Well Excavation <br /> . Domestic/private <br /> Drilled Dia. of0ell Casing <br /> Domestic/public. ;� <br /> Driven Gauge .of. Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Rotar ,.,.,.._...TYp �ofvGr.out <br /> i Cathodic Protection y,. . ,: <br /> Disposal. � Other � Other Information <br /> Geophysical Surface Se Ll Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �f . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 DABS <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 isrue to the be my knowledge and belief. I WILL FOR A GROUT INSPECTI <br /> PRIOR TO GROUON <br /> AND A INAL E ON. <br /> � SIGNED TITLE <br /> (DRAW PL PLAN ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> i ADDITIONAL COMMENTS: PHASE II FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY �} <br /> 1177 2M. <br /> s cu /.1 L T) 1_7A .. - <br />