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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Stockton, Calif . " <br /> FOR OFI"ICE USE:q ,r. 1601' E. Hazelton Ave. ,. �� <br /> w' f - Telephone • (204). 4666781 permit No. �� <br /> `. APPLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT <br /> Y_ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> Date Issued 7 . <br /> (Complete In Triplicate) <br /> Application is hereby made to ct <br /> the San Joaquin�5°aalllicationDistmade in compliance twith 5anuJoaquin� <br /> and/or install the caork herein described: Pp <br /> =the Rules and Regulations of the -San Joaquin Lacal, Health District. <br /> County Ordinance No. 1.862 and <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION : <br /> Ph one <br /> Owner's Name <br /> Cj_ty <br /> Address <br /> Phone <br /> License It I <br />'. Contractor's ;Name <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN / / <br /> RECONDITION I I DESTRUCTION /7 '' <br /> PUMP INSTALLATION I PU REPAIR / I PUMP REPLACEMENT I <br /> {4 Other / I - <br /> SEWER LINES ' - PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE.DISPOSAL FIELD PUBLIC DOMESTIC WELL _ („ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WETL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL � <br /> a Industrial Cab ie Tool Dia. of We11 Excavation <br /> Drilled Dia. of Well Casing <br /> t Domestic/.private Driven Gauge of Casing <br /> Irrigation <br /> " De th of Grout Seal <br /> :7,,..:_. _ ,.G�'aveJ- Pack P <br /> irrigation Type of Grout <br /> e Cathodic Protection RotarOther Other Information <br /> Disposal -- Surface Seal Installed Ii <br /> Geophysical <br /> ,4� <br /> PUMP INSTALLATION: Contractor - g,p, <br /> Type of Pup i <br /> PUMP REPLACEMENT: / / State Work Done \ <br /> State Work Donets J f <br /> PUMP REPAIR: I <br /> Approximate Depth. <br /> DES-TRUCTION OF WELL: Well Diameter \ <br /> Describe Material and Procedure <br /> lations of the San Joaquin Local Health District <br /> I hereby agree �o comply with all laws and reg u Within <br /> and the State of California pertaining to ori111furnshating ethecSantJoaquin.Local Health FIFTEEN District <br /> after completion of my work on a new well, above <br /> - the well in <br /> WELL DRILLERS REPORT of the well annhffttiI WILL CALL FOR AeGROUT eINSPECTION <br /> information is true to the best m y knowledgemandore belie <br /> PRIOR TO GROUTING 46Q A FINAL ON. TITLE ' <br /> SIGNED DRp,W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 110, DATE — <br /> t APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTIONINSPECTION BY t' DATE <br /> f INSPECTION BY DATE <br />