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T - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> . .x 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 Ia".1,2- <br /> (Complete <br /> I1(Complete .In Triplicate) <br /> Application is hereby made to the Sara Joaquin Local ,Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin' <br /> County Or-dinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />~JOB ADDRESS/LOCATION ,�.;�-� R c{ .-. CENSUS TRACT <br /> 5 <br /> Owner's Name � � ! � Phone <br /> City <br /> Address / Ale <br /> Contractor's Name 4 ty, <br /> License #� �! Phone <br /> TYPE OF WORK (Check) : NEW WELL /,47�_ DEEPEN / / RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> PUMP ,INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK fev SEWER LINES Lgl± PIT PRIVY <br /> SEWAGE DISPOSAELD -- CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE'CrPRIVATE DOMESTIC' WELL W� 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 /> t. Domestic/p <br /> ublic Driven., Gauge of Casing <br /> - Ii`iigatibn Gravel-. Pack .Depth of Grout Seal <br /> Cathodic�Protectian <br /> Rotar e �� Type of Grout <br /> r �• Y , <br /> Disposal Other-: Other Information <br /> Geophysical` w �� Surface Seal Installed By : eo <br /> PUMP INSTALLATION: Contkactor H.P. ' <br /> .a Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / Stare Work Done <br /> DESTRUCTION OF WELL: Well Mamet r 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 before putting. the well in use The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED . a . - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: RqnmT�T <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE INSPECTION B <br /> G' lx lli7Fi Rav_ 1-74 ` <br />