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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 701 *OFFICE USE: 1601, E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 7 � APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to �the Sun 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 a d he Rules an gulati ns of he Sari Joaquin Local Health District, <br /> Oldl Z f <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Namef — - Phone � ) Q 1'��_ <br /> Address �� City "Tc ��Jll/ <br /> Contractor's Name „ (J License,# Phone -7r 6 z I O <br /> TYPE OF WORK {Chuck): NEW WELL DEEPEN/_7 RECONDITION /_7DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/� PUMP REPLACEMENT -7 k <br /> Other '% / f <br /> �i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY UN <br /> SEWAGE -DISPOSAL FIELD C S�L/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS F a <br /> Industrial, J. Cable Tool Dia." of Well Excavation <br /> Domestic/private Dri1.7 d Dia. of Well Casing n <br /> Domestic/public Driven Gauge of Casing •� <br /> Irrigation I . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal A Other Other Information <br /> Geophysical. Surface Seal Installed By'. <br /> j# <br /> PUMP INSTALLATIONo Contractor } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth, <br /> ��Describe'Ma`terial 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 regulat: ng 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" above$ <br /> information isktr=ue <to the.best .of,my knowledge,and be <br /> NGlief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI 'AND A TINAL'INSPECTION. t ' <br /> SIGNED --- ^-4 TITLE meati, <br /> (pRAW�PLOT PLAN- ON REVERSE SIDE <br /> ..;FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE - ) 7 <br /> ADDITIONAL COMMENTS: ; <br /> PRASE IZ GROUT INSPECTION' PHA INSPECTION.nr <br /> INSPECTION BYDATE INSPECTION BV ;r -:' PAT <br /> F. u 7L9H ue., 7_7G isY h�75 2M <br />