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X/Y JOAQUIN LOCAL HEALTH DISTRICT <br /> ?OFx:OFFICE USE: 1601;--E. Hazelton Ave. , Stockton, Ca1:LA.. <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 <br /> (Complete In Triplicate) <br /> �p lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> runty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> =B ADDRESS/LOCATION LOO'SAaaaV4CENSUS TRACT <br /> rner's Name Phone /6 9Q <br /> 1dress _ _� f �. City <br /> 8�- d <br /> intractor's Name~ License # Phone <br /> .PE OF WORK (Check) : NEW WELL /X/ DEEPEN -/-7 RECONDITION ./-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /% PUMP REPAIR/_7 PUMP REP / <br /> Other / / MOMAOV <br /> :STANCE 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 y Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Of <br /> (n <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: n1.t< ' d <br /> W INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <br /> !MP REPLACEMENT: / J State Work Done <br /> '.REPAIR: / / State Work Done <br /> ,-S•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure C <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State of California pertaining to or regulating wel I 'construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a ; <br /> ELL 'DRILLERS REPORT of the well and notify them before putting. the -well in use.. The above . <br /> nformation is true to the-best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ZIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE, <br /> (DRAW PLOT PLAN ON REVERSE SIDE)) <br /> FOR DEPARTMENT USE ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY DATE .--j\A- -1([ <br /> DDITIONAL COMMENTS: <br /> PHASE II GROn INSPECTION PHA FINAL INSPECTIO <br /> NSPECTION BY DATE INSPECTION BY , P; ';�.. DATE <br />