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USAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR- 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 <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 <br /> /San Joaquin Local Health District. <br /> JOB �ADDRESS/ / Q`/ `� CENSUS TRACT <br /> t l7�/L Phone <br /> owner's Name Mlf, <br /> Address City <br /> Contractor's Name License Phox �� <br /> TYPE OF WORK (Check) : NEW WELL // DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION X1 PUMP REPAIR _/_I PUMP REPLACEMENT / I <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINESPIT PRIVY <br /> SEWAGE ,!AISPO L FIELD r CESSPOOL/SEEPAGE PIT/_e OTHER -r- <br /> d"= .' PROPERTY LIN PRIVATE DOMESTIC WELL 7.0- PUBLIC DOMESTIC WELL "^^� <br /> INTENDED"'US-E' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k Industrial "' I Cable Tool Dia. of Well ExcavationJ �/ I <br /> Domestic/private ! Drilled Dia".-of Well._Cas�ing Q <br /> DbiaesCic/.public t Driven Gauge ,of Casing s <br /> Irrigation i Gravel Pack Depth "of .Grout Seal v <br /> F <br /> Cathodic Protection Rotary Typeidf Grout <br /> Disposal �— Other. "�`" _ Other Infoation <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -:- <br /> 1 PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP .REPAIR: / / State Work Done <br /> a DESTRUCTION OF WELL: Well Diameter <br /> ximate Depth <br /> Describe Material and P � cedure <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 /> 7 . <br /> after compl�tion•,a. of my work'. on a new well.,. i_Hlll_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 is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1 PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> j SIGNED I <br /> (D LOT ON REVERSE SIDE) <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I "�! DATE 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t� P I/F NAL INSPECTIO <br /> PW II ' 9OUT X INSPECTION DATE 2. 7 <br /> INSPECTION BY ' 1DATE. INSPECTION BY <br /> b/77 _ 2M <br />