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i J <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF_OFFICE USE: 1601 E., Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION F& WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZKILp I <br /> THIS PERMIT EXPIRES, 1 YEAR tROM DATE ISSUED Fate Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San JoaquA 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. 18621 and the Rules and Regulations of. the San Joaquin Local -Health District. <br /> JOB ADDRESS/LO1v�O 7� Jean'e- CENSUS TRACT <br /> Owner's Name e Phone <br /> Address 3 City i <br /> Contractor's Name License 1)7��hon� � <br /> I <br /> F EPEN RECONDITION DESTRUCTION TYPE OF WORK (Check-)-: NEW WELL­/ DE / / / <br /> PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT <br /> Other Qj <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 /> IndustrialCable Tool Dia, of Well Excavation n <br /> Domestic/private. <br /> Industrial .. <br /> Drilled Dia. of Well Casing <br /> Domestic/public r Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysica. Surface Seal Installed By: <br /> PUMP INSTALLATION: = Contractor <br /> _Type of Pump H.P. <br /> PUMP' REPLACEMENT:' / / State Work Done <br /> f PUMP .REPAIR: / ./ State Work Done <br /> } 1. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j <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 thewell 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE1i0� __ <br /> (DRAW PLOT PLAN ON REVERSE SIDE}``" <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_,111/FINAL INSPECTION <br /> INSPECTION BY DATE 11-n- INSPECTION BY DATE Z <br /> v� 2M <br />