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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;.FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � d . <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. f <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Namel_ rhont <br /> Address City f <br /> { <br /> Contractor's Name J , License # f29D Phone51/_ .5- s <br /> an f <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / O <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER&)ell so <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONS �. <br /> Industrial Cable Tool. Dia. of Well Excavation 1/°' CA <br /> Domestic/private Drilled Dia, of Well Casing _ �� <br /> Domestic/public Driven Gauge of Casing zV a4& <br /> Irrigation Gravel Pack Depth of Grout Seal SID' <br /> Cathodic Protection y _ Rotary Type of Grout Aae 2k� ,I _ <br /> Disposal Other Other Information LIV— <br /> Geophysical Surface Seal Installed 8y: l}�ra�Dd.f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Dane <br /> n <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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."constructi.on. 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND,A FINAL INSPE TION. 1 <br /> SIGNED TITLE 1� <br /> J15RAW PLOT PLAN g REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , TJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE � <br /> ooD ' o/77 2m <br /> - <br />