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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �� <br /> t <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In. Triplicate) <br /> k <br /> Application is hereby made toIthe 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. 1$62 n the Rules and Regulations of t San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION GV CENSUS TRACT <br /> f <br /> Owner's Name - Phone <br /> Address /' CU � City <br /> License Phone <br /> Contractorvs Name ° /-j '` � - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/�'I DEEPEN // RECONDITION / / DESTRUCTION /7 T tiC1 <br /> PUMP INSTALLATION ILj PUMP REPAIR / I PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEARESTSEPTIC�TANK SEWER LINES PIT PRIVY <br /> : <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 /> t _ Industrial j ,,44Cable Tool Dia. of Well Excavation <br /> Domestic/private # Drilled Dia. of Well. Casing ��1'��i" �] <br /> Domestic/p <br /> ublic Driven Gauge of Casing T �• ' ' Cy --�-- <br /> yi 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 L <br /> Type:j'of Pump H.P. /,;7, <br /> PUMP REPLACEMENT: / / State Work Done <br /> + PUMP .REPAIR: I I jS•tate Work Done <br /> Depth <br /> DESTRUCTION OF WELL: Well I Diameter <br /> Approximate <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 REPO R of-the well and notify them before putting the- well in use.. The above <br /> ' information is tru to the best of my knowledge and belief. 1 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A F NAL NSP- CTI <br /> TITLE <br /> SIGNED <br /> (DRLOT PLAN ON REVERSE SIDE} <br /> Ati <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> P SE GROU INSPECTION PHASE /FIN _ INSPECT N <br /> INSPECTION BY DATE / INSPECTION BY DATE <br /> 6177 2M <br /> V N 1G7h Rau- . 1-74 <br />