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i <br /> SAN JOAQUIN LOCAL;HEALTH DISTRICT <br /> "FOE.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ) X,7-7d <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 the San Joaquin Local Health District.; <br /> JOB ADDRESS/LOCATION ' r` ems,, CENSUS TRACT <br /> Owner's Name t {/v <br /> )C4 Zo Phone <br /> Address City '- <br /> Contractor's <br /> ity .Contractor's Name , License # Phone , <br /> TYPE OF WORK (Check): NEW WELL /7 `.DEEPEN '/_7 RECONDITION %? DESTRUCTION <br /> PUMP INSTALLATIQN '/ / PUMP REPAIR/_] PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO, NEAREST: SEPTIC TANK SEWER LINES IT 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 <br /> Doines�ic/private 'Dri11@d Dia. of Well Casing <br /> Domestic/public Driven `"p Gauge of Casing <br /> IrrigationGravel Pack '; Depth of Grout Seal <br /> Cathodic Protection_ Rotar <br /> " y"" � � �" Type of Grout <br /> Disposal °° 1,.., Other Other Information ' <br /> Geophysical -g Surface Seal Installed 'B <br /> PUMP INSTALLATION: . Contractor.t <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �T <br /> PUMP REPAIR: /? State Work Done <br /> DESTRUCTION OF WELL: Well DiameterDepth <br /> Approximat �S <br /> Describe Material and Procedure -• <br /> Fit'r-fa CC + C�i'� ; <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of. Cal.ifornia'_pe.r.taining -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 District .a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -wellin use... The above <br /> information is true to-the-beir-of:;my..knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TOG UTING DA FINAL INSPECTION. ' <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> /t�`J] ; <br /> APPLICATION ACCEPTED BY DATE �7 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT IN VECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATA <br /> E H 142E <br />