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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 7 a <br /> 1 (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 Joaquino <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1. <br /> i CENSUS TRACT <br /> JOB ADDRESS/LOCATION � <br /> Owner's Name .. ' C Phone _ <br /> Address City <br /> License #--� c�oPhone ?6 7 <br /> Contractor's Name � �1 � �• -S � �`�' � . . <br /> TYPE OF WORK (Check) : NEW WELL /�/ DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PUIMP REPAIR /M PUMP REPLACEMENT 1_7 <br /> othe <br /> PIT PRIVY <br /> SE <br /> DISNCE TO NEAREST: SEWAGE DISPOSAL FIELDWER LINE <br /> TACESSPOOL/SEEPAGE PIT OTHER <br /> c <br /> PROPERTY LIME - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> _INTENDED USE ^� TYPE OF -WELL CONSTRUCTION SPECIFICATIONS <br /> Industr`ia1 ^�' =' Cable Tool Dia. of Well Excavation <br /> Domestic/.,private 1. �. .-: ;h Drilled Dia. of Well Casing , <br /> in Gauge Domestic/p l Driven e o£ Cas ' <br /> ublic g ; <br /> Irrigation ��-A VA, -i " ```�Gravel Pack1. Depth of Grout'Seal <br />' Cathodic Protection Rotary Type of Grout <br /> Disposal , ... .4 _- r-Other Other Information <br /> j.-'� Surface Seal Installed By; <br /> Ge'ophysical, <br /> PUMP INSTALLATION; Contractor I ' H.P. 1° n , <br /> wd Type of Pump <br /> PUMP REPLACEMENT: / / II State Work Done <br /> PUMP '.REPAIR: State Work Done <br /> / / t <br /> DESTRUCTION OF WELL: Well Diameter � Approximate Depth <br /> Describe Material and Procedure <br /> t � <br /> d regulations of the San Joaquin Local Health District <br /> jI hereby agree to comply' with all laws an re g <br /> and the State of Californialpertaining 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 <br /> WELL DRILLERS REPORT of the well and notify theCALL m before putting.the. 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 GPKTING D A FIM I PECTION. <br /> TITLE <br /> `> <br /> ;,. <br /> ' <br /> :SIGNED �`Y ., <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: r <br /> PHASE II 0 INSPECTION PHA I N INSPECT N ' <br /> INSPECTION BY <br /> + DATE INSPECTION BY DATE <br /> 1//7 2M <br />