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SAN JOAQUIN LOCAL'.HEALTH. DISTRICT <br /> Er- <br /> OFFICE USE• 1601 E. Hazelton Ave. , Stockton, Calif.Telephone: (209) 466-67810 FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.APPLICATI N it Date issued <br /> '17-7 <br /> THIS PERMIT' EXPIRES 1 REAR FROM DATE ISSUED <br /> N (Complete In Triplicate) <br />. Application is hereby made to the aaquhisoapplicationHealth District made inrco pliancetwithnSanuJoaquin <br /> and/or install the work;:herein described. <br />� County Ordinance u e Rules and Regulatio s of San Joaquin Local Health District. <br /> J ��J CENSUS TRACT t <br /> JOSDRESS/LOCATION <br /> u.+ .. 41i12U� Phone <br /> Owner's Name <br /> City <br /> I Address 'T/ <br /> ` <br /> -License icense # �%��� hone ,--dl /z0- <br /> Contractor's Name //1/. <br /> c <br /> NEW WELL &( <br /> DEEPEN '/_I RECONDITION I / DESTRUCTION 1_7 <br /> TYPE OF WORK (Check) : it <br /> : I :PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT J <br /> "Other <br /> ` F EWER LINES PIT PRIVY <br /> I DISTANCE' TONEAREST: SEPTIC TANKL <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> ' <br /> PROPERTY LINE :- PRIVATE DOMESTIC WELL WELL PUBLIC DOMESTIC <br /> �N CONSTRUCTION SPECIFICATIONS l� <br /> INTENDED USE TYPE OF WELL p <br /> ��- Industrial ' Cable Tool Dia. of Well Excavation <br /> ' Drilled Dia. of Well Casing <br /> �i <br /> Domestic/private <br /> I� Domestic/pub'lic i< Driven Gauge of Casing :�- <br /> I Gravel Pack Depth of Grout Seal <br /> � Irrigation '' <br /> IM Cathodic Protection Rotary Type of Grout <br /> k .IM Disposal Other Other Information <br /> I[ Geophysical Surface Seal Installed B '. C <br /> V PUMP INSTALLATION:' Contractor <br /> Type of Pump H.P. <br /> E <br /> IState Work Done <br /> PUMP REPLACEMENT: I <br /> PUMP -.REPAIR: li / / State Work Done f <br /> Approximate Depth t <br /> iDES•TRUCTION OF WELL: Well Diameter <br /> ;i Describe Material and Procedure. <br /> f .l <br /> District <br /> ,-I hereby agree to 'comply with all -laws and regulations of the San Joaquin Local, Health <br /> Mand the State of .California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> liafter completion of my work on a new well, I will furnish the San Joaquin Local Health District <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. TWILL CALL FOR A,GROUT INSPECTION <br /> MRIOR TO GROU G A' A FINAL INSP 0 TITLE <br /> F <br /> SIGNED <br /> { (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE+ <br /> ' Q � <br /> APPLICATION ACCEPTEDrBY - - - <br /> ADDITIONAL COMMENTS: PHASE /FINAI, INSPECTION <br /> PHASE II GROUT INSPECTION DATE y7 <br /> INSPECTION BY r-r DATE INSPECTION BY --- <br /> 2M <br />