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SAN JOAQUIN LOCAL HEALTHDISTRICT <br /> FOE 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 6-,;I-7J <br /> i (Complete In Triplicate) <br /> Application is hereby made tolthe 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 Joaqu: <br /> County Ordinance No. 1862 andithe Rules and Regulations <br /> pp of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> L11 Phone 3 6 <br /> Owner's Name /`�^7 2 <br /> Address Z/O �(�� �_ �F �it �- City p ry <br /> Contractor's Name License iyiL� Phone3r,Q-J <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION % <br /> PUMP INSTALLATION / / PUMP REPAIR `/ / PUMP REPLACEMENT jg <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 /> - - -- <br /> Type of <br /> PUMP REPLACEMENT: �. <br /> "¢Q State.Work <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ss . <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 ori a new well, I will furnish the San Joaquin Local Health District : <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 ofmy/'knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A FIiNSPEION. <br /> SIGNED TITLE <br /> WPOTT PLAN ON UffkSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` • (�• (' /X DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION -zimASE_.III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /J-'✓ DATE <br />