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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 0TZFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> { Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No." 11 w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F ( (Complete In Triplicate) 0 '(q — !30 35 <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 /> vil 4 - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address !J L!� ' City .a3 3 `�er �7 <br /> Contractor's Name.,' <br /> i License L�Phone� <br /> TYPE OF WORK (Check): NEW WELL/DEEPEN '/? RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION A PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE,DISPOSAL FIELD 7 D� CESSPOOL/.SEEPAGE PIT OTHER Z <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �moble Tool Dia. of Well Excavation L " <br /> !,--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> I- Cathodic Protection + Rotary Type of Grout SRS ` F, <br /> ".Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMPjINSTALLATION: Contractor ' <br /> /j Type sof Pump •x H.P. ! <br /> PUMPiREPLACEMENT: / / State Work Done <br /> PUMP REPAIR`-� '- ` /� 'State Work Done <br /> ,RES•TRUCTION OF WELL: Well Diameter APproxima�e Depth <br /> Describe--Material and-Procedure <br /> I hereby agree to,comply with alljaws and regulations of the San Joaquin Local' Aea3:th 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-the..well in use.. The above <br /> information is true to the best' of uiy kt�owledgE and;belief. ' I WILD`-CALL FORA GROUT INSPECTION <br /> PRIOR TO GROYJ4NAND A F INSPECTION. <br /> SIGNED TITLE -- <br /> + (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I e7 <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE III FINAL INSPECTXON <br /> INSPECTION BY DATE .�"`•� INSPECTION RBY DATE 2 <br /> k ' 1 7\N r \��' qtr: . jam .. y 1 1-74 2M _ <br /> �i E $ 1425 Rev.. <br />