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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> EOR OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.?Z - 9//,0) <br /> U � THIS PERMIT 1EXPIRES I YEAR FROM DATE ISSUED Date Issued' )- � <br /> y (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;jherein 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 Di.str�ct. <br /> NI. <br /> JOB ADDRESS/LOCATION j o CENSUS TRACT <br /> Owner's Name12 11 <br /> Phone <br /> Address �. <br /> d / city <br /> Contractor's "Naine� License PhoneyJ`�/SZ <br /> TYPE OF WORK (Check) : NEW WELL Lj DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK It SEWER LINESZ� PIT PRIVY <br /> SEWAGE DISPOSALF�'.ELD — CESSPOOL/SEEPAGE PIT OTHER --- <br /> PROPERTY LINE �'RIVATE DOMESTIC WELLZQQf+ PUBLIC DOMESTIC WELL Gj <br /> INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 'Industrial Ca <br /> bl.e Tool Dia. of Well Excavation /y�' tai <br /> Domestic/private i, Drilled..- --� Zt_ 'Dia, of Well, Casing <br /> Domestic/public j Driven Gauge of.Casing .' <br /> _ Irrigation ;� Gravel Pack Depth of Grout Sea] UV <br /> Cathodic Protection Rotary Type. -of Grout <br /> Disposal Other Other Inf rmation <br /> Geophysical - �� S ce ea Installed By: <br /> i , <br /> PUMP INSTALLATION: Contractor ' ��'�"� -•- �' <br /> Type of Pump ! H.P, 3 <br /> PULP REPLACEMENT: / -/ State Work Done <br /> PUMP .REFAIR: State Work Done <br /> y T i <br /> kDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r 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 Califonia pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> rafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of 1the well and notifyshem. before putting the well in use. The above <br /> j. information is true -to the. best f kn wl ge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND FINAL SP IO , <br /> SIGNED !I, TITLE <br /> �. ( RA OT PLAN ON .REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> ACCEPTBYAPPLICATIONDATE <br /> ADDITIONAL COMMENTS: <br /> GR <br /> PHASE <br /> INSPECTION BY .II DATE I _ <br /> OUT INSPECTION PHAS I/FIN INSPECTION <br /> INSPECTION BY DATE r <br />