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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. y 7-.T5/6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) q <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 Rule and Regulations of t San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT �da dam.. CENSUS TRACT <br /> Owner's Name Phone <br /> Addresses d City G� <br /> r <br /> Contractor's Name � / -d License # 9 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / <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 CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia, of Well Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of, Grout'Seal "' <br /> Cathodic Protection` Rotary Type. of Grout- _ <br /> Disposal Other, t Other Information <br /> Geophysical Surface Seal Installed By: <br /> _PUMP INSTALLATION: Contractor 7/ <br /> Type of Pump --- - H.P. <br /> PUMP REPLACEMENT: State Work Done '` <br /> PUMP ,.REPAIR: / / State Work Done { i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 pertaifiing to or regulating well "construction, Within FIFTEEN DAIS <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 CAL OR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND -A F L INSPECTIO <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUT INSPECTION PHASE ,j7V/FINAje INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 77 r <br /> F H IL9A ➢e.. 7-7/. 1177 "2M I <br />