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II SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFOr, OFFICE USE: I•.. 1601 E. Hazelton Ave.�, .Stockton, Calif. <br /> i Telephone:, (209) 466=6781 <br /> ( APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2,7-1113 <br /> i.� THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <br /> I! (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 Joaquii <br /> County Ordinance No. :18612 and the Rules and Regulations of. the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION f' '� Z . . �� '`�� CENSUS TRACT <br /> Owner's Name tj V , . I Phone 9) <br /> Address City - I JC/< / U <br /> Contractor's Namebl�' (�, 1 License it@ Phone`Q�- <br /> q <br /> TYPE OF WORK (Check) : iNEW WELL DEEPEN "/_/ RECONDITION DESTRUCTION /7 <br /> _ <br /> :PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> I�Other / / <br /> DISTANCE,. TCFNEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <br /> , f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC `l'P.UBLIC. DOMESTIC WELL <br /> x INTENDED; USE " TYPE PF WELL , CONSTRUCTION SPECIFICAYIONS <br /> Industrial ;,Cable Tool Dia, of Well Excavation /2 <br /> Domestic Dr' flled Dia, of Well Casing /Z <br /> /Private r. <br /> 'r ZD mestic/public Driven Gauge of Casing / <br /> rigat-ion Gravel Pack Depth of Grout Seal JAL)Q <br /> Cathodic Protection{ Rotary Type of Grout <br /> Disposal II Other= Other Information <br /> Geophysical ISurface Seal Installed By: <br /> PUMP INSTALLATION: I!Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I'— s <br /> PUMP .REPAIR: I�/ / State Work =Done <br /> tDESTRUCTION OF WELL: jWel1 Diameter Approximate Depth <br /> ;Describe Material and Procedure. g <br /> I hereby a ree'to comply with-ell 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 myjNwork on a new well., I will furnish the San Joaquin Locar Health Districta <br /> WELL DRILLERS REPORT of the-well and notify them`before putting the. well,"insuse... The above <br /> { information is true.,toilthe best of my~knowledge and-belief. 'I WILL CALL FORA GROUT TNSPE"CTION <br /> PRIOR TOG. UTINGOAN AFI-MM, <br /> I SPECTION. ~. <br /> SIGNED TITLE <br /> `t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i ® Y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> �PAPPLICATION ACCEPTED BY .p DATE <br /> 1 .ADDITIONAL COMMENTS: �j� <br /> PHASE II GROUT INSPECTION PHAS T /FINAL INSPECTION <br /> 1 INSPECTION. BY 11 DATE INSPECTION BY DATE -*�S-`17 <br /> ° �I of 77 2M ' <br /> .yE 1426 Rev. • 1-7.4 <br />