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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF.01'F E "USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. .fes <br /> Telephone : (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �3� THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED' Date Issued ! � <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 Na. 1$62 andhe Rules and Regulations of the San Joaquin Local Health Dist4ct. <br /> "lo fr l +r jZp <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address ,� sEx oN 5,2 <br /> City . . � <br /> Contractors Name License f <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INST21YATION / / PUMP REPAIR —PUMP ✓ ,p <br /> . Other REPLACEMENT /'7 <br /> D STANCE TO NEAREST• SEPTIC TANK (a SEWER ZINES «��. PIT PRIVY �` <br /> SEWAGE DISPOSAL FIELD .� CESSPOOL/SEEPAGE PIT OTHER .�. <br /> PROPERTY LINEPRIVATE DOMESTIC WELL X12_' PUBLIC DDMESTIC WELL -�- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECTFICATiON$ � \ <br /> Industrial _ Cable Tool Dia, of Well Excavation '11 <br /> Domestic/private Drilled Dia. of Well Casing h <br /> Domestic/public Driven Gauge of Casing "V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary¢ .. y _Type of Grout <br /> Disposal -Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> an. <br /> PUMP INSTALLATION: Contractor ,A 7 14, <br /> Type of Pump <br /> H.P. - <br /> PUMP REPLACEMENT / / !State. Work Done~` <br /> PUMP .REPAIR: State Work Done <br /> ~ r <br />)ESTRUCTION OF WELL: Well Diameter g <br /> �.- Pproximate Depth <br /> Describe ,Material and Procedure . <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 i <br /> TELL DRILLERS REPORT of the well and notify them before putting the .well, in use. The above <br />.reformation is true to the es o€ y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR T ING D A F S <br /> SIGNED TITLE <br /> (DRAW PLOT FLAN ON. REVERSE SIDE) <br />'RASE T FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE - Z <br />.DDITIONAL COMMENTS: - <br /> *PS,gGROUjeINSPEC_T_11O_N_ PHASE I/FIN INSPECTION <br /> NSPECTION BY DATE -7 7� INSPECTION BY <br /> tgg <br />