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ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. P6-3,'S'k-1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7( <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 CENSUS TRACT <br /> Owner's Name Phone <br /> Address Cityir ,z Ll <br /> Contractor's Name - License # 7 60z PhoneZ- <br /> TYPE OF WORK (Check): NEW WELL `/I�( DEEPEN -/? RECONDITION %f DESTRUCTION %j <br /> PUMP INSTALLATION /� PUMP REPAIR'/-7 PUMP REPLACEMENT f7 <br /> Other /-7 . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK AFff 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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: i <br /> / / State Work Done <br /> PUMP :ItEFAIR: <br /> /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure . <br /> y <br /> I hereby agree to comply wit all laws and regulations nf the San Joaq n L cal He It Distri <br /> and the State of California pertaining to orregulating well "construction. Witham FIFTEEN DAYS <br /> after 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 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 GROUTI AND A FINAL INSPECTION. ; <br /> SIGNED 1 . - - TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION' ACCEPTED BY DATE ' �fo <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE 115 <br /> E 'H 142 r Re" w�4 y r r <br />