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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE .OFFICE USE: 1601 E.. Hazelton Ave. ; Stock-ton, -Calif,. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5__1__ j_ <br /> ! (Complete In Triplicate) <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 /> JOB ADDRESS/LO ATIONi S TRACT <br /> r <br /> Phone <br /> Owner's Name <br /> Address L <br /> City <br /> i <br /> ' License 4� Phone <br /> Contractor's Name <br /> A <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 1_7 ` . <br /> 4 Other / / e <br /> V <br /> ell <br /> ---------------- <br /> DISTANCE TO NEAREST:. f� SEPTIC TANK� SEWER- LINES PIT PRIVY <br /> 1 SEWAGE DISP `'FIELD- GE OOL/SEEPAGE PIT OTHER (� <br /> PROPERTY LINE - PRIVATE-DOMESTIC,WELt PUBLIC ..DOMESTIC WELL <br /> INTENDED USE TYPE OF W LL CONSTRUCTION SPECIFICATIONS <br /> ° Dj-6--of-�We-11.Excavation + <br /> Ix strial able Tool <br /> omestic/pr.ivate I Drilled Dia, of Well Casing �� <br /> Domestic/public 1 Driven Gauge ofCasing <br /> Irrigation I Gravel Pack /Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst91Te_d-B -: <br /> _.�-.. . <br /> PUMP INSTALLATION: - -Contractor T- - <br /> 4 _Type" off--Pump-- �. .=. �•--- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done <br /> k Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter . . . r' <br /> Describe Material and Procedure <br /> i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District , <br /> and the State of Californialpertaining to or regulating well "construction. Within FIFTEEN DA�,S <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 thej-well and notify them before putting the well in use.. The above <br /> information true to the b st of my knowledge and belief. I WILL LL FOR A GROUT INSPECTI <br /> 1" PRIOR TO GR AND A F I PECTION. <br /> SIGNED TITLE <br /> (DRA PLOT PLAN ON REE SI <br /> VERSD <br /> FOR DEPARTMENT USE ONLYPHASE I - <br /> 4 <br /> APPLICATION ACCEPTED BY f �- DATE �'"y t <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE -7 INSPECTION BY fDATE <br /> N <br /> 'IL <br /> 9A Palr 1-7/L <br />