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Ca, / ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi, ICE USE: 1601 E. Hazelton Ave. , 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 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 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 �1 3~1 S 44V 4_116 CENSUS TRACT <br /> Owner's Name pk.1" Phone , <br /> -Address / S- �' /f r� ,� City <br /> Contractor's Name 4 <br /> License # one o <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/7W RECONDITION /7 f <br /> DESTRUCTION / <br /> PUMP- INSTALLATION -/ / PUMP REPAIR /mac-] 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 Cable Tool Dia. of Well Excavation <br /> _ X Domestic/private Drilled Y Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> -Geophysical `"�"��� <br /> - Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump cu rn @�rr'i01 H.P. j ? <br /> PUMP REPLACEMENT: , / / 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 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 Distric <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 <br /> knowledgeand belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR R UTING AND A FINAL IN PE <br /> SIGNE ITLE LOT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE qi FINS_ , INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Z_ DATE <br />