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SAN JOAQUIN LOCAL. HEALTH DISTRICT { <br /> EOR.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-67,81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued_z_ 7 . <br /> ' (Complete In Triplicate) <br /> Jplication is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> zd/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 /> F)B ADDRESS/LOCATION Q CENSUS TRACT <br /> Fmer's Name Phone <br /> Address [�.G" - City <br /> '-X <br /> intractor's Name 0) License { d�d� Phone1�W/,4 <br /> r_'PE OF WORK (Check) : NEW WELL %/ DEEPEN -/_7 RECONDITION 1-7 DESTRUCTION /7 4 ) <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other - --- -- - -- <br /> k :,STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 1r' 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 - A.: <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other --. Other Information <br /> Geophysical Surface Seal Installed B : <br /> �. <br /> � ' INSTALLATION: Contractor <br /> Type of Pump H.P. P, <br /> FLMP REPLACEMENT: / / State Work Done <br /> Pr <br /> UMP .REPAIR: State Work Done&tee <br /> � 7SJRUCTION OF WELL: Well Diameter. Approximate Depth ' <br /> �.� Describe Material and Procedure <br /> ]'hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> _-d 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 /> FALL DRILLERS REPORT of the well and notify them before putting the -well in.use. The above <br /> J -formation is true to th best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING AND AL INSPECTI-0 <br /> UGNED TITLE <br /> �` ( RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> e� PLICATION ACCEPTED BY "� _ DATE Z-31-2,5P,'e DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION . _ <br /> I-SPECTION BY DATE INSPECTION BY DATE <br /> 1 !P77 +�+r <br />