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}� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L l7 { <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 ti r Phone <br /> AddressSf Yrs _ City . , <br /> Contractor's Name License # r,4jJ%7Phone �:1— <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR '/ / PUMP REPLACEMENT %-' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER INZ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _� PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial 'Cable"Tbol Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing (n <br /> Domestic/public Driven Gauge of Casing.! �►1 <br /> Irrigation Gravel Pack Depth of Grout-Seal ` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal— ._",Other Other Information <br /> GeophysidAl Surface Seal Installed By: <br /> In <br /> PUMP INSTALLATION:- , Contractor - <br /> Type "of Pump- H.P. <br /> PUMP REPLACEMENT: State Work Done /���`t r- 7 <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"'-aad 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's nish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in use. The above <br /> informat- on-as_.t. e to tJe-best o.f-jny_,knowledga and belief,_I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI_aQ AND A,FI IN PECTION.. � ` } <br /> SIGNED '`� ' �. " TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �P ' � <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASA III FIN INSPECTI N - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> /V V I <br /> R 1-i l A'l F ne.. 1--21. <br /> 1777 - 2M / <br />