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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> OOFFICE SEFU1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 1+66-6781. ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DateIssued <br /> (Complete In Triplicate) <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 t e San Joaquin Local Hehlth District. <br /> JOB ADDRESS/LOCATION l = [ CENSUS TRACT <br /> Owner's Name zz e./ r Phone „��/� g-7 Z/z <br /> Address City �A% ;G C- <br /> Contractor's Name License <br /> n� z <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%% RECONDITION /% DESTRUCTION /-7 y <br /> PUMP INSTALLATION"§�F PUMP 'REPAZR / / PUMP REPLACEMENT <br /> r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �t <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 <br /> D� Domestic/private i Drilled Dia. of Well Casing; it <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By, 57 <br /> PUMP INSTALLATION: Contractor , <br /> Type of ,Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> y <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />- - <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 ''constructidn. Within FIFTEEN DAYS <br /> after completion of my work on `a new well, I will"•fdrni_sh the San Joaquin Local Health District a <br /> W'4LL DRILLERS REPORT of-the weld: antinotify thein'before `putfit g tlrie'-:�' 11 in use: The atzove <br /> i�i�formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO N AND A FINSPECTION. <br /> f <br /> IGNED — <br /> ` TITLE ` <br /> � ! OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - k <br /> ADDITIONAL COMMENTS: - <br /> PHASE II G P TION PHkkSEIW,FINAL- <br /> INSPECTION <br /> INAL INSPECTION BY 4�' — 1ATE7f T--a0 -77 INSPECTION BY DATE -_o'j. <br /> :•?x]i �L•7� ve.. 7_�i. 1177: F <br />