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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> X73 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. I` <br /> JOB ADDRESS/LOCATION /� r fJ �, !'• CENSUS TRACT 1 <br /> V r-41 <br /> Owner's Name g Phone- ' <br /> Address City <br /> Contractor's Name �j ✓W7`u'`� F7 License ��� 1V Phone <br /> TYPE OF WORK C�,eck) : NEW�WELL /DEEPEN REC_mnIT QN_4-/ RUL I i�. <br /> _� _ <br /> PUMP INSTALLATION / / PUMP REPAIR/ /i PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k 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 /> Dometirc-/TubI- Vic---..__ L�/ Driven Gauge of C"ing . <br /> k Irrigation i Gravel Pack Depth of Grout-,Seal <br /> Cathodic Protection Rotary Type of Grqut <br /> Disposal Other Other Information , <br /> GeophysicalSurface Seal Insta 'led By: <br /> _ � X <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done41 <br /> rp <br />' PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 'Approximatie`Dep•th-- <br /> 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 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 <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 FPR A GROUT INSPECTION <br /> PRIOR TAL INSPECTION. <br /> SIGNED It lo TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _Z�����_ <br /> ADDITIONAL COMMENTS: <br /> PHA GROUT INSPECTION P dI /!IN INSPECTION -/ <br /> `. INSPECTION BY DATE INSPECTION BY DATE <br /> " ` 1/T7 2M <br />