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SAN JOAQUIN LOCAL HEALTH DISTRICT �P <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, <br /> THIS PERMIT EXPIRES I YEAR -FROM DATE ISSUED Date Issued/_ r <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 /> N CENSUS TRACT i <br /> JOB ADDRESS/LOCATION <br /> r <br /> Phone <br /> Owner's <br /> Owner's Name C <br /> c a City AEZC"9 Al <br /> Address J f <br /> Lieenste jQf0 Phone o <br /> Contractor's Name <br /> `~,�r DESTRi3CTION <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / REG N'D -/-/ <br /> PUMP IN�ST�ALLAfION -' UMf' REPAIR / / PUMP REPLACEMENT I <br /> = Other / `f <br /> DISTANCE TO NEAREST 1_S,EPTIC TANK SEWER LINES PIT PRIVY <br /> ��_� ,✓ SEWAGE DISPOSAL FIELD CESSPObL/SEEPAGE PIT OTHER �I <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 _ ,n <br /> Drilled Dia. of We1:l. Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public F <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> i Surface Seal Installed By : <br /> Geophysical <br /> tom; V <br /> PUMP INSTALLATION: Contractor <br /> + HP. <br /> Type of Pump _ <br /> . � <br /> 5 PUMP REPLACEMENT• j_/ State('WarkDone..-----. , <br /> PUMP REPAIR: / / State Work Done _------ .- <br /> Approximate -Depth, . -�: <br /> DES-TRUCTION OF WELL - Well Diameter E 1,: `, .- , <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of1the 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 furnishithe 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 FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND A INAL INSPECTION. TITLE <br /> SIGNED - <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: P SE- I /FIN NSPECT ON <br /> PHASE II GROUT INSPECTION TE <br /> INSPECTION BY DATE INSPECTION B <br /> fa/77 2M <br />