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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQF OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued ,�?-.�9-9 <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 RegulationsCof the San Joaquin Local Health District. <br /> S] ENSUS TRACT <br /> JOB ADDRESS/LOCATION f Al- .517 J2 t- <br /> Phone <br /> Owner's Name /v at <br /> 2+a <br /> City �.Q /� <br /> Address o N L�1 C f` y <br /> Contractor's Name 4:f> C- 1't s Licens�fJ�f � 3 Phoneme S-' f 3 S —� <br /> F� <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN / / RECONDITION I I DESTRUCTION. -7 <br /> ,,,,PUMP INSTALLATION /!�/�PUMP REPAIR,/ / PUMP REPLACEMENT <br /> *.. i <br /> ther <br /> W <br /> DISTANCE TO tNE-AREST: SEPTIC TANK/6 0 SEWER LINES P1IT PRIVY <br /> SEWAGE DISPOSAL .FIELD CESSPOOL%SEEPAGE PIT OTHER <br /> ' PROPERTY LINE � PRIVATE DOMESTICR-WELL �' -PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL � .u. `�CONSTRUCTION SPECIFICATIONS r <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled ' Dia. of Well Casing f <br /> Domestic/public Driven Gauge o --Ca—sing Cg <br /> Irrigation Gravel Pack Depth of Grout Seal - "^ <br /> f A. <br /> Cathodic Protection �_ Rotary Type of Grout ��, <br /> Disposal Other Other Information <br /> Ceop,h'sical Surface Seal Installed By: <br /> .11 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i / <br /> PUMP REPLACEMENT. State Work Done <br /> f r <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 District a <br /> I.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 /> PRIOR TO GROUTING AND A FINAL INS ECTION. <br /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY jag r > DATE 7 <br /> }ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BY DATE ✓ t <br />