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JOAQUIN LOCAL HEALTH DISTRICT <br /> `?h OFFICE 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 1 YEAR FROM DATE ISSUED Date Issued <br /> t " <br /> (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local health District for a permit to construct <br /> ./or install the work herein described. This application is made in compliance with San Joaqu <br /> my Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District <br /> ADDRESS w <br /> CENSUS TRACT <br /> l e r's Name <br /> Phone <br /> .rens <br /> City <br /> tractor's Name <br /> License at /7a-�-Phone <br /> OF WORK (Check) : NEW WELL / DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUPU' INSTALLATION , PUMP REPAIR -/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> INCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT ,� OTHER <br /> PROPERTY LINE��pRIVATE DOMESTIC WELL -6/2 PC78LIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 5PECIFICATIONS <br /> Industrial _�— Cable Tool Dia. of Well Excavation ; <br /> _ Domestic/privatesDrilled <br /> Domestic _�_ Dia. of Well Casing <br /> /public Driven Gauge of Casing <br /> Irrigation — , <br /> Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection �� Rotary Type of Grout �-.- <br /> Disposal Other Other Information \ <br /> _Geophysical <br /> Surface Seal Installed By: , <br /> INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. 7. <br /> ZEPLACEMENT: . i_/ State Work Done <br /> 3EPAIR: / / State Work Done r <br /> r <br /> JCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> 'by agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> to State of California pertaining to or regulating g ng we11'constructio <br /> completion of m w n. Within FIFTEEN DAYS <br /> y work on a new well, I will furnish the San Joaquin Local Health District a <br /> 'RILLERS REPORT of the well and notify them before putting the-well in use.. The above <br /> ation is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> :�O GROUTING AND A FINAL INSPECT <br /> �PLOFTLANREVERSE SIDE) <br /> z FOR DEPARTMENT USE ONLY / <br /> ITION ACCEPTED BY <br /> ONAL COMMENTS: DATE — 7 <br /> PHASE II GROUT ECTION PHASE III/ INSPECTION <br /> DATE , <br /> TION BY INSPECTION BY r►ATa <br />