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SkWJOAQUIN LOCAL HEALTH DISTRICT1� <br /> F OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ��/G� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /.;I-� <br /> (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br />/or install the work herein described. This application is made in compliance with San Joaquin <br /> aty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ADDRESS/LOCATION �M [ _ jjQ A/ r(7n•r�• CENSUS TRACT <br /> arts Name $�� OrAIVC F_z_� Phone <br /> f <br /> ress a <br /> City . -yC& T/ <br /> tractor's Name License Phone��o�7 <br /> E OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION {_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT f_7 <br /> Other <br /> LANCE TO NEAREST: SEPTIC TANK Opp SEWER LINES <br /> _Z ,VLr 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 SPECIFICA_TI_ONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br />_ Domestic/public Driven Gauge of Casing /a S <br />_ Irrigation Gravel Pack Depth of Grout Seal S-10 <br /> Cathodic Protection Rotary Type of Grout <br />_Disposal Other Other Information Nt <br />—Geophysical Surface Seal Installed By: ^ L" <br />' INSTALLATION: Contractor <br /> Type of Pump — H.P. rp <br />• REPLACEMENT: / / State Work Done <br />• REPAIR: / / State Work Done <br /> CRUCTION OF WELL: Well Diameter Approximate Depth \w1 <br /> Describe Material and Procedure �1 <br /> �reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />;r completion of my.-work on' s new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well, and notify them before putting the well in use. The above <br /> irmati�oni"s true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1R TO JTjj q AND A AL INSgiE'C'PION. <br /> 4ED YL-6 T-(�r_ TITLE <br /> Jd&DDRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 3E I / _ <br /> .ICATION ACCEPTED BY / DATE <br /> LTIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 'ECTION BY DATE INSPECTION BY DATE <br />