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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FO `�,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> '. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is 1�ereby made tothe San Joaquin Local Health District for a permit to construct' <br /> is made in compliance with San Joaquin <br /> and./or install the work herein described. This application <br /> e Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862„ and th <br /> ��� � <br /> JOB ADDRESS/LOCATION �J . ICG .— CENSUS TRACT , <br /> ~r ! � Phone - <br /> Owner's Name _ <br /> City , <br /> ,Address 5V + <br /> License # Phone <br /> Contractor's Name S f <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION I/ PUMP DESTRUCTION <br /> N/7/7 <br /> - PUMP INSTALLATION / / PUMP <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 5ffl SEWER LINES PIT PRIVY �f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTR� C� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION 'SFECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation �7 <br /> Drilled Dia, of Well Casing ' <br /> Domestic/private t <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation 1_44 Gravel Pack Depth of Grout Seal 'Ilk <br /> l Cathodic Protection -- Rotary Type of Grout <br /> E Disposal Other ` Other Information <br /> Geophysical ; Surface Seal Installed BY: <br /> le/e,1-}-7 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> oo <br /> t PUMP REPLACEMENT: / / State Work Done A <br /> PUMP <br /> REPAIR:' _ r / /State Work Done =-W <br /> t. . <br /> App imate Depth <br /> DESTRUCTION OF WELL: Well, Diameter <br /> Describe Material and Procedure <br /> herebyagree to comply with uction all laws and regulations of the San Joaquin Loc <br /> I S . Within FIFTEEN DAY <br /> al Health istrict <br /> and the State of California pertaining to or regulating we11 'constr <br /> Joaquin Local Health District a <br /> after completion of my work ;on a new well, I will furnish the San <br /> WELL DRILLERS REPORT of thewell and notify them before putting the well 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 GROU ING AND A FI L PE CT ION TITLE <br /> SIGNED <br /> 1 (DRA PLOT PLAN ON RE SE SIDE) <br /> ' FOR DEPARTMENT E ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pHp,SE III/FI AL INSPECTION. <br /> PHASE II GROUT: INSPECTION INSPECTION Big DATE �� <br /> INSPECTION BY ! DATE <br /> 77 _ <br /> n, l-7 h <br />