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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOE OFFICE. USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 /> s (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 Sen Joaquin <br /> County Ordinance No. 1862 and the Rules' and Regulations of the San Joaquin Local Health District. <br /> k JOB ADDRESS/LOCATION / /L dLI ,_ fv CENSUS TRACT <br /> Owners Name Phone ' Q . <br /> s <br /> Addres , <br /> �. _. _ �City: <br /> Contractor t s Name _ ,Q � r„„�� License #,I(g_ 7 Phone <br /> TYPE OF WORK (Check): NEW WELL '/7DEEPEN '/_ :}RECONDITION _fDESTRUCTION /7 <br /> PUMP INSTALLATION / / P� REPAIR �/ 'PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER4LIS PIT PRIVY <br /> SEWAG&iDISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE �- PRIVATE TIC WELL' PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE QF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial + tD, <br /> able Tool Dia. of Well Excavation <br /> Domestic/private rilled Dia. of Well Casing <br /> —Domestic/public r �riven Gauge of Casing <br /> Irrigation t Gravel-Rack Depth of Grout Seal <br /> Type of Grout <br /> -Gathodic Protection Rotary <br /> Isisposal t Other Other Information <br /> Geophysical 'Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. L <br /> PUMP REPLACEMENT: '-, State Work Done <br /> puv_ � <br /> j PUMP :REPAIR: /-7 ::State Work Done <br /> DE&TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regula a '`ons of the an Joaquin Local Health District <br /> And the State of California pertaining to or regu ting well `c ns.truction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will urnish the an Joaquin Local Health District a <br /> WELL DRILLERS REMT of the well and notify them b .f6re putti.ni.the .well. in use.... The above <br /> information is e t the t -of- my.knowledge a belief. I WILL CALL FOR A GROUT INSPECTION <br /> kPRIOR TO GROU GAN A PIb INSPE CTI <br /> 'SIGNED TIT i <br /> aL(DRAW PLOT PLAN ON REVERSE ISI-DE <br /> FOR DEPARTMENT USE ONZry� r' <br /> PHASE I j, ,/ <br /> APPLICATION ACCEPTED BY i " <br /> DATE 7 7G <br /> ADDITIONAL COMMENTS: ._ <br /> ' PHASE II GROUT INSPECTION Pugg IN FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE-1076- <br /> M E H 1416 Rev. Y1-74 4 a . ' 1 /75 2M <br />