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i SAN JOA UIN LOCAL HEALTH DISTRICTlk <br /> FOR OFFICE USE: { � � 1601 E. Hazelton Ave. , Stockton, Calif. � `��`��°;.vr" 4i�"" 5�S <br /> L1 Telephone: (209) 466-6781 <br /> 4 <br /> b;' b APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Data Issued lz- 75" <br /> Fr (Complete In Triplicate) <br /> Application: is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I <br /> rnd/or 'install the work herein described. This application is made in compliance with San Joaquizi <br /> 1. <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> 1aners Name Phone ,'��'J✓ (� I <br /> �ldress <br /> City H <br />` Contractor's Name License #�0, f Phone <br /> _ RECONDITION _ DESTRUCTION /- <br /> TYPE OF WORK (Check) . NEW WELL / DEEPEN REC�N� I-T <br /> PUMP INSTALLATION 17,7 PUMP REPAIR /� PUMP REPLACEMENT �T <br /> Other <br /> s <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 SPECIFIC IONS oe <br /> r-, 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 -A;-D <br /> Cathodic Protection Y Rotary Type of Grout <br /> : ,, Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:- -- <br /> INSTALLATION: <br /> :INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> FW REPLACEMENT: / / State Work Done <br /> PUMP ;REPAIR: /? State Work Done ' <br /> �--.STitUCTION OF WELL: Well Diameter <br /> Approximate De <br /> Describe Material and Procedure <br /> 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 /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ' ;LL DRILLERS REPORT of the well and notify them before putting. the..well in use.. The above <br /> Laformation is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ,I :GNED .:,}.: ='' > ': " TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ti ASE I <br /> } 'PLICATION ACCEPTED BY DATE z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROU I SPECTION j PHASE III FINAL INSPECTION. , <br /> '-SPECTION BY DATE -� 7� INSPECTION BY DATE -,�3 <br />