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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> M <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.) 1D6 �7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(Complete In Triplicate) 2If ?—It o- 3 <br /> 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> Q-02Ze 9 �It <br /> JOB ADDRESS/LOCATION j, N CENSUS TRACT <br /> Owner's Name F . Phone <br /> Address /Op, City <br /> eZ <br /> Contractor's Name D �' License #47 eld Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /_/ PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing �s <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 /> and the State of California pertaining to or regulating well 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 well in use. The above <br /> information i ue to the best my knowledge°and belief. I WILL CAL4 FOR A GROUT INSPECTION <br /> PRIOR TO GRD IN AND A FINAL EC <br /> SIGNED TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,� , DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II ECTI PHAS I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 _74 2M } <br />