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Z `-"` SAN JOAQUIN LOCAL HEALTH DISTRICT 015F0 OFFICE USE: i� . . 1601 E. Hazelton. Ave. ; Stockton, Calif. <br /> Telephone : (209) 466-6781. � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. rT��LQS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �9 ' 7d <br /> t (Complete In Triplicate) ... <br /> `r Application is hereby made to the San Joaquin Local Health District for a permit to construct .r <br /> and/or install the work herein described. This application is made in compliance with San ,Joaquir <br /> County Ordinance -No.-118,,62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LYaEQ CENSUS TRACT <br /> r -- <br /> Owner's Name Q Phone <br /> Address y: S City <br /> Contractor's Name KA License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN j / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTMATION j' / PUMP REPAIR / / PUMP REPLACEMENT /_7Other <br /> C <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation �r <br /> Domestic/private Drilled Dia, of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ;Z47— <br /> Cathodic Protection Rotary Type of-Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �. D lye H.P. <br /> PUN? REPLACEMENT: State Work Done <br /> PUMP' AEPAIR: # / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter , Approximate Depth <br /> -22 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of myi�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 tothe best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A�D ): NALINSPECTION. <br /> SIGNED TITLE _ V <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 3 i i,. '-'+_ —,_._.._... _.._ FOR DEPARTMENT^USE ONLY <br /> PHASE I �.. ci 'rt f <br /> APPLICATION ACCEPTED BY DATE 1)_n <br /> `. ADDITIONAL COMMENTS <br /> PHASE 11 G TINSPECTION PHASE IIIIFIRAL INSPECTION <br /> i INSPECTION-,.BY '` j, r I�.,, , .,, DATE INSPECTION BY ,��i' DATE <br /> E H 1426 2M <br /> _Rev. <br />