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`E <br /> SAN JOAQUIN LOCAL -HEALTH DISTRICT CIOFOA. `yy3CE ISE: " 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 <br /> (Complete In Triplicate) f <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> '!L-1-7s/ A) • D6' cJ4r,Ez _ f 7V <br /> JOB ADDRESS/LOCATIQN CENSUS TRACT <br /> Owner's Name Phone <br /> Address, 3 W City_ •G ► <br /> Contractor's Namd"� �4_�_h ` License <br /> a <br /> TYPE OF WORK (Check) ; NEW WELL ] / DEEPEN / / RECONDITION / / DESTRUCTION /_7 _ } <br /> PIMP INSTALLATION /- / PUMP 'REPAIR / / PUMP REPLACEMENT- <br /> Other <br /> EPLACEMENT0Cher <br /> DISTANCE TO NEAREST: SEPTIC TANK j\0rte_ SEWER LINES PIT PRIVY 4 j <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 X Cable Tool Dia, of Well. Excavation JL J/ - <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal n n <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed- <br /> By.,:-PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 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 w6rk �6n- a. new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofB6 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 G OUTING D A F,INfIL INSPECTION. <br /> SIGNED . .- <br /> TITLE <br /> (DRAW PLOT PLAN ON -REVERSE SIDE) T <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I � <br /> APPLICATION ACCEPTED BY r DATE Z <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION P SE i /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY( DATE <br /> E H 1426 Pp.._ . 1-7L 2M <br />