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fSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.'OFFICE USE: < ' 160.1 E. Hazelton Ave. , Stockton, 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 <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 jgpquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT r <br /> Owner's Name LIDp0 Phone 93 2 <br /> Address CityTO�I�T <br /> Contractor's Name LAW ' a EQ. r <br /> r License �� �� Phone � �'�c� ' <br /> 4 <br /> TYPE OF WORK (Check) : NEW yWELL / DEEPEN /A/ RECONDITION / / DESTRUCTION /_ ri <br /> PUMP INST ATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 4 <br /> "—SEWAGE DISPOSAU'FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 <br /> t PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 'WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> dustrial Cable Tool Dia. of Well Excavation- & <br /> Domestic/private Drilled Dia. df' We11-.,Casing <br /> Domestic/:public Driven Gauge of Casing _ <br /> Irrigation.[ avel Pack Depth of Grout Seal f <br /> Cathodic Protection Rotary Type of Grout Ut <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> I� <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR.: / / State Work Done <br /> DESTRUCTION OF WELL: , Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> fI 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.,.the well7in 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 G ING AND A NAL INSPECTION. <br /> SIGNEDTITLE + <br />'tIf TDRAW PLOT PLAN ON REVERSE SIDE) <br /> Z, FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATEp�04 <br /> - 5 <br /> ADDITIONAL COMMENTS: N <br /> j <br /> PHASE--iIj GROUT INSPECTIONI PHASE III/FINAL INSPECTION ' <br /> INSPECTION BY DATE 7 INSPECTION BY DAT y <br /> { 7 2M <br />