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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR_­OFFICE USE; ''` I6U1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 <br /> Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Districtfor 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 AOCATION � <br /> CENSUS TRACT <br /> Owner's Name .� 1 � '�� *79 J <br /> Phone <br /> Address f <br /> City � _C'iC1 <br /> Contractor's Name <br /> -12 <br /> Q License # Phone �iJ" 02� <br /> J <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 'PROPERTYLINE---- PRIVATE DOMESTIC WELL �_ PUBLIC DOMESTIC WELL <br /> INTENDED USE ' - TYPE OF WELL <br /> Industrial s CONSTRUCTION SPECIFICATIONS <br /> " `�` Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing \ <br /> Domestic/public ; , .Driven Gauge o. as <br /> f Ci <br /> Irrigation ng <br /> p� } <br /> Gravel Pack Depth­:of Grout Seal \1 t <br /> Cathodic Protection Rotary <br /> _e; Grout P <br /> Disposal .,�- <br /> Other Informatioi? <br /> Geophysical w Surface Seal Installed B : fi <br /> PUMP INSTALLATION: Contractor .,Y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> I` / <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROU N AND A FLNAL IN PECTIU . <br /> 31GNED <br /> TITLE _ <br /> D LOT PLAN ON REVERSE SIDE) <br />'RASE I <br /> R DEPARTMENT USE ONLY k <br /> APPLICATION ACCEPTED BY DATE <br /> DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II 0 S TION PHAS I I/FIN INSPECTIO' <br />.N SPECTION BY DATE INSPECTION BY DATE "J <br /> E H 7G9F, n __ 1 71 �C <br />