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SAN JOAQUIN 'LOCAL HEAL 14 DISTR1Ci' <br /> FOh�,OFFE 1SE 1601 E. Hazelton Ave. , Stockton, Calif . lop <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3` <br /> • f <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 hereinidescribed. This application is made in compliance with San-Joaquin <br /> County Ordinance No. 1862 and the Rules and Re u1 ti.o s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ ��Z GLN!iUS TRACT <br /> Owner's Name �� �t,,,� Phone C 3 - 992-1 <br /> � ��-� f <br /> �. �..'r <br /> Address City <br /> 6�qpv 5 2:2 1V31 <br /> Contractor's.- Name License # hone <br /> v - <br /> TYPE OF WORK (Check) : NEW WELL/� DEEPEN / / UI CONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 jz: <br /> Other / / _j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD 'CESSPOOL/SEEPAGE PIT OTHER (� <br /> PROPERTY-LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICWNS <br />�dustrial i Cable Tool Dia. of Well Excavation r �/ <br /> Domestic/private Drilled Dia. of Well Casing — _- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Iravel Pack Depth of Grout Seal <br /> Cathodic Protection '. Rotary Type of Grout <br /> Disposal t Other Other Information 4 - (W� __ <br /> Geophysical , Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of{Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> — � t <br /> PUMP .REPAIR: / / State-Work Done - = <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth s <br /> Describe Material and Procedure <br /> I 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 we11''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local' Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the . 1 in se. The above <br /> information is true to the best of my-k wledge and belief. � I WIL C L FO GROUT N=SP CTION <br /> PRIOR TO GaLNG AND A FIN NS .E.CTI ��` <br /> SIGNED i ,�-� .TITLE <br /> DRAW PLT LAN 'ON RE FRSE SID ) <br /> } FOR DEPARTMENT USE ONLY i <br /> PHASE I i <br /> APPLICATION ACCEPTED.,BY DATE l� <br /> ADDITIONAL COMMENTS: 1 <br /> PHAS {- I ROUT INS ECTI N PHASE III/FINAL ,INSPECTION <br /> INSPECTION BY ' DATE & INSPECTION BY DATE'- - Q- <br />