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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OF'FICE 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 l YEAR FROM DATE ,ISSUED Date Issued 7 31_7g' <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 /> JOB ADDRESS/LOCATION0c CENSUS TRACT ' <br /> Owner's Name l Z Q G _ Phone <br /> AddressCity <br /> Contractor's Name �-� 1 n/ ,4z �2, j)jY License # 17.'4'V Phone -L It;2 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN -/7 RECONDITION/7 DESTRUCTION J f <br /> PUMP INSTALLATION G/ PUMP REPAIR -/ PUMP REPLACEMENT / a <br /> Other / / — <br /> 1 <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 ~l <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information � . <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor [ !Type of of Pump T ! P , A.P. . <br /> PUMP REPLACEMENT: / / State Work Done a <br /> PUMP .REPAIR: ,® <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxima 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 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 trVD <br /> o the•best-of my..knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING A,-FINAL INSPECTION. <br /> SIGNED ,�L• `-`%�I t � f TITLEf-Q, <br /> L� DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , c� <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION P INAL INSPECTION <br /> INSPECTION BY DATE INSPIICTION DATE <br /> & 1..., — I <br />