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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> NK70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> >^ Telephone: (209) 466-6781 <br /> AjP APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S- SDLtJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / <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 grade 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 Al - S. ENSUS TRACT <br /> Owner's Name Phone � "� <br /> Address City <br /> Contractor's Name License # 0 1�5 Phone `�.22/Q <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN -/-7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR-1_7 PUMP REPLACEMENT 17 <br /> Other /-7 <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing '12 <br /> Irrigation Gravel Pack Depth of Grout Seale <br /> Cathodic Protects <br /> Rotary Protection... � y Type of Grout <br /> -Disposal - ��"�"�1�� <br /> Other Other Information � -, <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br />- PUMP ,REPAIR: /_7 State Work Done � \ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 7 <br /> N <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 District a <br /> WELL DRILLERS REPORT of the well and notify them before putting-the..well in use... The alcove <br /> information is true to the-best of. my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING°AND INS ION ` <br /> SIGNED C ITLE ?� :c <br /> DRAW T P N SE SIDE <br /> EP T USE ONLY <br /> PHASE I ma <br /> APPLICATION ACCEPT <br /> DATE . �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL 2NSPECTION <br /> INSPECTION BY SPECTIONBY D <br /> Ze . <br /> E H 1426 - �. <br />