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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&:OFFICE USE: 1601 E. Hazelton Av <br /> : e. , 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 I ed <br /> (Complete In Triplicate) <br /> Application is hereby made to. the San Joaquin Local Health District for a perm to construct <br /> and/or install the work herein described. This application is made- in compl nce with San Joaquin <br /> County Ordinance No. 1862 Pand the Rules and Regulations of the San -Joaquin.. focal Health District. <br /> JOB ADDRESS/LOCATION �! y/ �jC C� SUS TRACT <br /> Owner's Name 21-Wf,41 �. S Phone ?i�!o1,3 sS <br /> Address <br /> Contractor's Name Li Onse11Eo7 <br /> yea s�so <br /> TYPE OF WORK (Check) ; NEW WELL '/—f DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' PIT 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 m <br /> Cable -Tool' � �---Dia: �nf�Well Excavation <br /> Domestic/private ;: Drilled .,, Dia. of Well Casing <br /> Domes.tic/public- ^�-.� �. =� Driven`_-- Y Gauge-of Ca!31ng-- <br /> Irrigation <br /> Gravel-Pack—-Deptll-of:'Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION. Contractor .K - - Q <br /> Type .of Pump H.P. <br /> OZ <br /> PUMP REPLACEMENT: /7 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_mand-regulations..-of-.the San Joaquin Local Health District <br /> and the State of California pertainipg 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 C <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 GR UT 'AND A FINAL INSPECTION. ! <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION a° P FIN INSPECTION <br /> INSPECTION BY DATE _ INSPECTION B DATE f'- --7 <br /> �/0 S�MP�E �`�'° /✓.f .SGL <br /> F R iL9ti ate.__ 1-7L A<.�//✓�� <-✓i U / . J �. <br />