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�� SAN JOAQUIN LOCAL HEALTH DISTRICT Wim_ <br /> FOPS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> gAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zlz- Sy <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 0 I-s-0-C6-p <br /> Application is hereby made to the San Joaquin Local Health District -for a permit to can t� ruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862yand the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO Gt;r }r CENSUS TRACT <br /> Owner's Name Phone F - - Y,Z, <br /> Address ,�� City + <br /> Contractor's Name License #/( 7.3 Phone <br /> TYPE OF WORK (Check): 'NEW WELL/-7 DEEPEN /-7f <br /> RECONDITION /-T DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—PUMP REPLACEMENT , <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 C15 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Z ' <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 Other Information <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. S <br /> / tate Work Done <br /> PUMP �REPAIR: /-7 State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth T <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 true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A 19IN44PINSPECTZON. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE 7/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROJIT NSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE3 <br /> 4 E H 1426 Rev. 1-74 1-74 '2M <br />