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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> SOF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i ; <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 �� L/ - CENSUS���� �;f ^ - CENSUS TRACT <br /> Owners Name <br /> �2Q �� <br /> e 1. - �ra� _ Phone <br /> Address _ .20 i ,2�-- S--- / _ l__��n/ /�l City <br /> Contractor's Name License �� �1/�/ Phone /S j <br /> µ 4 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7Other — <br /> DISTANCE TO NEAREST: . SEPTIC TANK _ �' SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 5 <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 . /7 �1 .S? <br /> Domestic/private Drilled Dia. of Well Casing 2 '► <br /> Domestic/public Driven Gauge of Casing 0#2 <br /> Irrigation - -Gravel Pack , Depth of Grout Seal . <br /> Cathodic Protection Rotary Type of Grout _ 2 AALw, IL <br /> Disposal Other Other Information <br /> Geophysical ti Surface Seal Installed 'B : <br /> a <br /> EPUPP INSTALLATION: Contractor s <br /> Type of-Pump r H.P. , <br /> PLN -FMUCEMENT: / / State Work Done <br />-PUIV .REPAIR: Stata,-Work Done ` - --- <br /> DES,'TRUCTION OF WELL: Well Diameter.F ! ---- - - - - -Approximate Depth ro <br /> Describe Material and Procedure <br /> Ihereby agree tocomply 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 /> affer 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 befor.e';putting the.-well in use. The above <br /> i��ormation is true to the be, t f m owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRI��R TO G ING AND FIN P N. <br /> SWNED TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PAIASE I <br /> APRLICATION�ACCEPTED BY /"_9 <br /> DATE /�Z <br /> ADDITIONAL COMMENTS <br /> PHA I OU INSPECTIONPHA i/ N INSPECTION <br /> INSPECTION BY BATE INSPECTION BY DATE <br />