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SAY -OAQUIN LOCAL HEALTH DISTRICT <br /> /L 4601 H✓Hazelton Ave. , Stockton, Calif <br /> TEOFFICE USE: w/ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete�,In Triplicate) permit to construct <br /> ilication is hereby made to the San Joaquin Local Health District for a p with <br /> 3/or installanty Ordinance No. 1862eandnthedescribed. <br /> andThis <br /> Regulationsapplication <br /> the SaneJoaquinin pLocal eHealth SDistrictin <br /> �.77/ 41 � /4W CENSUS TRACT <br /> B ADDRESS/LOCATION �0 <br /> Phone D oo �.27' <br /> 1 r <br /> ner s Name <br /> -Se- hum L�SG74J u <br /> City <br /> dress m LL <br /> i 9 License ll Phone g � 7 <br /> ntractor's Name /,Q,SJ <br /> PE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION_/ / DESTRUCTION /=T <br /> PUMP INSTALLATION KJ PUMP REPAIR / / PUMP REPLACEMENT /=T <br /> Other / / <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> OS <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 G` <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ <br /> Cathodic Protection Rotary Type of Grout n <br /> Disposal <br /> Other Other Information <br /> —Geophysical Surface Seal Installed Bv: <br /> _ <br /> UMP INSTALLATION: Contractor D— H.P. <br /> Type of Pump %X ,j <br /> UMP REPLACEMENT: / / State Work Done \ <br /> _ F <br /> 'UMP .REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C 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 /> sfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .JELL 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 INSPECTIO <br /> 'RIOR TO OUTI AND A FI NSPECTION. <br /> SIGNED a TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pHASE-F F INSPECTI N <br /> PHASE II GROUT I SPECTION <br /> INSPECTION BY DATE INSPECTION BY / G K DATE / �� <br /> 3/76 214 <br />