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iJOAQUIN LOCAL HEALTH DISTRIC <br /> FOF _OFFICE USE: 1601'.. Hazelton Ave. , Stockton, Cal*. <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 <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 in compliance with San Joaquir <br /> -ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT <br /> hener's Name L,Bi� 5-A V4 C IJ Phone <br /> f <br /> lddress f _ City _ <br /> ,ontractor's Name /LJ � , J License #A,.23,23Phone.36p�.31 <br /> 'YPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK Oar SEWER LINES 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 _ 16 _ <br /> Domestic/private Drilled Dia. of Well Casing _ 6 11 <br /> _ Domestic/public Driven Gauge of Casing / A <br /> Irrigation Gravel Pack Depth of Grout Seal _ p <br /> Cathodic Protection _ 1)( Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor Y ' <br /> Type of Pump _ H.P. <br /> 'UMP REPLACEMENT: / / State Work Done \\ } <br /> 'UMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 /> 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 /> RIOR TO 9WTI,*G AND ANAL INSX=ION. <br /> IGNED TITLE 224yy f A <br /> 1,{,4DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'HASE I <br /> PPLICATION ACCEPTED BY DATE ^` / ! <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTI0N BY DATE INSPECTION BY DATE <br />