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SAN JOAQUIN, LOCAL HEALTH DISTR?CT ' <br /> FOF OFFICE USE: 1601 E. Hazerton" iie. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applica-tion is he eb 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,I <br /> County Ordinance No. 1862 and the-Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S'" �' CENSUS TRACT <br /> Owner's Name Phone 017--, <br /> i <br /> Address jy Cit <br /> s 1 <br /> Contractor's Name / �-- <br /> _. /�•4 -/lo�+y �2i jfiia+ �� License �� Gp� Phone ? <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / /• -DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /7/-..PUMP REPLACEMENT /7 � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 2S ArSEWER LINES µp V-PIT 15RIVY <br /> SEWAGE DISPOSAL FIELD -dbm CESSPOOL/SEEP PE PIT �- OTHER <br /> PROPERTY LINE10-t PRIVATE DOMESTIC WELL F PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL % CONSTRUCTION SPECIFICATIONS <br /> � <br /> Industrial. � Cable Tool Dia.: of Well Excavation <br /> N]�3 <br /> x Domestic/private+ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing \1 <br /> Irrigation Ar Gravel Pack Depth of Grout Seal a <br /> Cathodic Protection � Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:!/o Ile <br /> 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 work on a new well, I will furnish the San Joaquin Local Health Difstrict ,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 IkISPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY ` . DATE Z, r <br /> ADDITIONAL, COMMENTS: <br /> A- <br /> FMSkp GROUT_INSP CTIONPHAS /F IIA INSPECN <br /> INSPECTION BY// DATE 2 ""7 7 INSPECTION BY DATE jTI } <br /> f ; <br /> t.- ~ETH- 1426 Ppu- , 1-71L } <br />