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SAN JOA UIN 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 I YEAR FROM DATE ISSUED Date Issued ��, <br /> (Complete In Triplicate) <br /> 1' 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 /> I County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . CENSUS TRACT <br /> Owner's Name Phone <br /> pG _ City d <br /> Address <br /> a <br /> Lice nse_4t_ Phone �D_3 <br /> Contractor's Name — <br /> TYPE OF WORK (Check) : NEW WELL " DEEPEN —/ RECONDITION / / DESTRUCTION /_7 ` <br /> PUMP INSTALLATION PUMP REPAIR '/—/ PUMP REPLACEMENT /� , <br /> Qther <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 /> ' <br /> Industrial 1 able Tool Dia. of Well Excavation 1k, C <br /> Domestic/private ! Drilled Dia. of Well Casing '� U <br /> Domestic/public i Driven. Gauge of Casing <br /> r �rrigation Gravel Pack Depth of Grout Seal <br /> r Cathodic Protection Rotary Type of Grout 7,7- <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed B E <br /> � f <br /> PUMP INSTALLATION: Contractor Y-6t,1_1", <br /> TYpeol ..Primp H.P. <br /> i <br /> PUMP REPLACEMENT:r / / State Work Done <br /> i 4.� , <br /> }State Work Done <br /> DES=TRUCTION OF WELL: Well DiameterApproximate Depth �— <br /> Describe Material and .Procedure <br /> II hereby agree to comply with al.lklaws' 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 /> ; atter 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 is true to the best ofamy krCdwledge'and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR ING ANR A FI ;INS ECTION. <br /> SIGNED TITLE ` <br /> (DRAO PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY v <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY DATE %” 7 <br /> 1177 _ 2M <br /> n 1} , �.�c n- - ,_-7i. - <br />