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kN JOAQUIN LOCAL HEALTH DISTRIC <br /> F0 OFFICE USE: 16[ E. <br /> Hazelton Ave. , Stockton, Ca.,-,.L . <br /> - <br /> Telephone: (209)- 466-6781 ( f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI� (�Cer., 0 Y I� �T <br /> J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedLf <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 incompliance with San Joaquin <br /> Count Ordinance No. 1862 and the Rule and Regulations of�th an oaq ir�al. alth ' trict. <br /> JOB ADDRESS/LOCATIONcr �- �� 7 <br /> a CENSUS TRACT <br /> Owner's Name Phone L5 5 - �C/e <br /> Address v x9c;V71 3 City <br /> Contractor's Name <br /> License # <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 /> CEJ �1 <br /> PUMP INSTALLATION: Contractor k <br /> "Type of Pump <br /> H.P. — <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done <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 GROLYrING AN NAL INSPECTION. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 0--J f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ f DATE 7 <br /> �• u ,!.�G „- - -„ o,�7 7 fur <br />