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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0__R*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -;W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7_l3 <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. 18 2 a d the Rule nd Regulations v the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � CENSUS TRACT_ ' <br /> Owner's Name 417 <br /> T /fes ° <br /> Address !/ jj� Ci <br /> Contractor's Name -�� 11 Licensej�F'",--?`�Phon,0491�9�— <br /> TYPE OF WORK (Check): NEW WELL -/7 DEEPEN '/? RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -12y,, PUNP REPLACEMENT f7 <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 _ ___ Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done e <br /> PUMP 'REPAIR: ( State Work .Don - - s- <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 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 GR UTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> -- FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY DATE ' L T <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /¢-21�1 <br /> E H 149f, <br />