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s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> FO) OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �_7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued V <br /> (Complete In Triplicate) 3* <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andIthe Rules and Regulations of the San Joaquin Local Health District. <br /> j <br /> CENSUS TRACT <br /> I JOB ADDRESS/LOCATIO <br /> tt 6� Yr <br /> I ?I Phone �W _ <br /> / <br /> Owner's Name �ic7l <br /> City <br /> j Address <br /> License ��� Phone %T <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN I_I RECONDITION / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other ,/ / <br /> DISTANCE TO NEAREST: SEPTICITANK 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 SPECIFTCATIONS _ <br /> ' <br /> Cable Tool <br /> I . `� �( ' --Dia. of Well Excavation <br /> ndustrial Q <br /> 'r`ivatet .-Drilled__ a of Casing <br /> .�. __- ,_ Dia. of..Well, Casing \, <br /> Domest'ic/p dGau �[ <br /> -Domestic/public I Driven g <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection k Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump .! <br /> i '. Fir •S- Q//'' /; � gam////�y//r � ��r �'r Y �i.! <br /> PUMP REPLACEMENT• / / State Work Dd4.i.iie&-. <br /> ' <br /> PLiMP 'REPAIR: IState Work Done <br /> I I <br /> kDES;TRUCTION OF WELL: Well Diameter <br /> 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 /> construction. Within FIFTEEN DAYS <br /> rand the State of California! pertaining to or regulating well on a ndw well, I will furnish the San Joaquin Local Health District a <br /> after completion of my work <br /> iWELL DRILLERS REPORT of the, well and notify them before .putting the well in use. The above <br /> information is true to the:: Lbest of my knowledge and belief. I WILL CAFOR A GROUT INSPECTION <br /> 'PRIOR TO GROUTING AN•D� FIN INSPECT;,0 N. <br /> � ,, �lJ ., TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> ' i f FOR DEPARTMENT USE ONLY <br /> jPHASE I DATE <br /> JAPPLICATION ACCEPTED BY 4- <br /> ADDITIONAL COMMENTS: PHASE III'/,FINAL INSPECTION <br /> PHASE II G OU INSPECTION INSPECTION-By DATE / <br /> ' INSPECTION BY DATE . r <br /> _.. _ 1177 . 2M <br />