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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF,.OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ 7 /� <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 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 /> JOB ADDRESS/LOCATION zSDx t V e E1 CENSUS TRACT <br /> Owner's NameocJj3 CcrP_ Phone 36 /'/I �a <br /> Address � � _ City 1 <br /> Contractor's Name License Phone <br /> f it <br /> E _ <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> ' PUMP INSTLATION ,�,� PUMP REPAIR / / PUMP REPLACEMENT I_T <br /> AL {{ <br /> Other / / <br /> DISTANCE Tq,"NEAREST: SEPTIC TANK O ,. -SEWER LINES PIT PRIVY <br />? SEWAGE DISPOS� IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE��_P.RI3IAT-E_DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation -le <br /> Domestic/private 'Drilled 1 Dia. of Well Casing <br /> Domestic/public Driven Gauge of-Casing <br /> `, Irrigation 'Gravel Pack� Depth of Grout Seal <br /> -,Cathodic Protection Rotary Type. of-Grout <br /> Disposal Other Other Anformation <br /> t Geophysical Surface Seal Installed By: <br /> (� <br /> PUMP INSTALLATION: Contractor; Gg <br /> Type of Pump_ H.P. <br /> PUMP REPLACEMENT _ <br /> ' / �T­S`ttr2e Work Done_ <br /> PUMP REPAIR: ,. - State Work-Dorie_.__ -- <br /> DESTRUCTION OF WELL: W611 Diameter Approximate Depth <br /> Describe Material and Pracedure ' <br /> h <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 DAIS <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 t wet and notify them before putting the well. in use.. The above <br /> information is true, to a best of now dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN NSPE 14 <br /> SIGNED TITLE <br /> ' RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II Dff INSPECTION PHASE III/FINAL INSPECTIgE <br /> INSPECTION BY DATE INSPECTION BY DATE Z 2 <br /> /77 2M <br />