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i <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE: ' -, 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> 1n�" Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date .Issued r-7I . l <br /> (Complete' In Triplicate) <br /> Application is Aereby 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 /> 1 <br /> JOB ADDRESS/LOCATION ,�/ CENSUS TRACT <br /> Owners Name _ _ <br /> ' _ j_I�-` . ��� Phone. <br /> Address City ' � /, ,�� <br /> Contractor's Name <br /> -�, t .�. �U .. License Phone <br /> i <br /> TYPE OF WORK (Check): NEW -!WELL /..7 DEEPEN '/� RECONDITION /� DESTRUCTION /�] <br /> A' PUMP. INSTALLATION /� PUMP REPAIR 0 PUMP REPLACEMENT /7 <br /> Othr / <br /> � I <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 i CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia.1of Well Excavation <br /> Domestic/private Drilled Dia.1of Well Casing <br /> Domestic/public Driven Gauge of Casing - � <br /> Irrigation Gravel. Pack Depth of-Grout Seal <br /> I <br /> - Cathodic Protection Rotary Type of ,G•rdut;` ll <br /> . Dispos.al � a A . Other Other -Information <br /> Geopkiysic `� t " 5 rf 'ce'S 1 Installed By <br /> u a ea nstall ' <br /> PUMP INSTALLATION:Y, Contractors , i <br /> �"tiType 0-i '.'Pump <br /> V < <br /> PUMP REPLACEMENT f / State Work Done <br /> PUMP .REPAIR: State Work.Done 6 r. <br /> .1 F fi <br /> DESTRUCTION OF WELL: Well Diameter 1 Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and reguiations. of the San Joaquin Local Hea1'th Miiiqt <br /> and the State of California pertaining to or regulatingtwell `construction. Within- FIFTEEN DAYS <br /> after completion of. my work on a new well., I will furnigh the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before 'phtting 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 GROUTIN D A FINAL4jNSPyrCTI0N. i <br /> SIGNED TITLE _ <br /> r (DRAW PLOT PLAN ON. REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � �� _- _ DATE �7`1 ,7 7 , <br /> IADDITIQNAL COMMENTS: <br /> PHASE II GRQU!LINSPECTION PHAS II FINAL INSP TOA[ <br /> INSPECTION BY DATE INSPECTION BY DATE rq <br /> V U ,lA*)A n--- 1 .. 7T� 1/7.7 _ 2H <br />