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SAN JOAQUIN LOCAL HEALTH- DISTRICT jCIO <br /> - '' 1601 E. Hazelton Ave. Stockton, Calif. <br /> FOR OFFICE- USE: ` <br /> 1. Telephone: (20;) ' 466- 6781- �i <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 Loral Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulatio s of the San .Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION //S .2 <br /> Phone <br /> Owner's' Name <br /> Address <br /> / SZ- City <br /> ,,�����- <br /> License ��rC hone 7 <br /> Contractor's Name <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/�/ RECONDITION / / DESTRUCTION /_T <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> } JOther / / — <br /> k DISTANCE -TO ,NEAREST: SEPTIC TANK SEWER LINES IT PRIVY <br /> _, SEWAGE DISPOSAL FIELD +'= CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION: SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � - <br /> Domestic/private w <br /> Drilled Dia. of Well Casing ` <br /> t a Driven �- Gauge',of _Casing ' ' <br /> omestic/public c� <br /> Irrigation Y :: ' ,`. Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary -- Type of Grout1 <br /> Disposal <br /> Other Other Information <br /> f Geo h sical Surface Seal Ins <br /> Ytalled B ,\ <br /> p _.d. �•L. - <br /> PUMP"INSTALLATION: Contractor H.P. <br /> iA Type of Pump" <br /> _ .A <br /> PUMP REPLACEMENT: t �/ State Work Done �1 .j <br /> i PUMP :,REPAIR: / /- .'State Work Done <br /> � DES4RUCTION OF WELL: Well Diameter <br /> f Approximate Depth '_ <br /> -- Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> sand the .State of California pertaining to or regulating well ••construction. Within FIFTEEN DAYS <br /> , after cos' letion 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..we11 in use. The above <br /> ! information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG D A FINAL I CT ION. TITLE } <br /> ' SIGNED (DRAW ' <br /> PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE I i DATE •� <br /> APPLICATION ACCEPTED BY f <br /> ADDITIONAL COMMENTS: -_., PHASE III/ INAI: INSPECT ON �� <br /> "PHASE-- II'GRDiTT' INSP�' TION - Y <br /> - DATE <br /> INSPECTION BY DATE ' <br /> INSPECTION BY ,.. ."y <br />