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� JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601-E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z�4d <br /> 77-0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquir <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> TOB ADDRESS/LOCATION CENSUS TRACT <br /> mer's Name , <br /> Phone <br /> kddress City <br /> ,5ntractor's Name Z42a=e 22-11License #, 2WeyPhone <br /> PE OF WORK (Check) : NEW WELL /Z:?<EEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /il�uMP REPAIR / —PUMP PUMP REPLACEMENT /- <br /> Other <br /> STANCE TO NEAREST: SEPTIC TANK ' -WER 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 ,1 2 " <br /> Domestic/private Drilled Dia. of Well Casing 12 <br /> D mestic/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 <br /> Surface Seal Installed By : 0. <br /> IMP INSTALLATION: Contractor , ��• n_� <br /> Type of Pump �T H.P. D <br /> TMP REPLACEMENT: / / State Work Done <br /> 'UMP .REPAIR: / / State Work Done <br /> ..STRUCTION 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 /> ►nd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> ifter 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 /> ,tiformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> :.GNED TITLE <br /> +� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> iASE I / <br /> "W PLICATION ACCEPTED BY { U J DATE L� , <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> .1SPECTION BY DATE INSPECTION BY DATE/ <br />