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SAN JOAQUIN I;&AL HEALTH. DISTRICT <br /> s _ <br /> FOE OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL__ZLU_j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /01-29 <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 Rule gulations of he San kaquin Local Health District. <br /> %E9 P19 <br /> JOB ADDRESS/LOCATION ENSUS TRACT _ <br /> . Phone �__��L�. <br /> Owner's Name' <br /> f <br /> / City L�ltf <br /> Address <br /> Contractor's Name ' <br /> License Phone .?��lC� <br /> i <br /> DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> TYPE OFtWORK (Check}; NEW WELL <br /> t• ,: .. PUMP INSTALLATION '// PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> ' Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK _Aajo� SEWER LINES PIT PRIVY <br /> G1lc1u � <br /> SEWAGE DISPOSAL FIELD Za CESSPOOL/SEEPAGE PIT OTHER Aq0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS cl <br /> Industrial <br /> Cable Tool Dia. of Well Excavation {�`� <br /> T� Domestic/private <br /> Drilled Dia. of Well Casing t V <br /> Domestic/public Driven Gauge of Casing <br /> � Irrigation <br /> Gravel Pack Depth of Grout Seal h <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information C <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the Sari 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 GROUTING AND FINAL NSPE ION. <br /> SIGNED TITLE d <br /> �; . <br /> W P ' T PLAN ,ONjAEVERSE SIDE . <br /> DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION .ACCEPTED,.BY <br /> ADDITIONAL COMMENTS:p <br /> PHASE II GRO T INSP CTI N. HA /FIN NSPECTIO <br /> INSPECTION BY , DATE INSPECTION BY ATE <br />