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SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> FRE7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 -sN 7 1cJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued g=,/D.-�� <br /> (Complete In Triplicate). " <br /> Application if; 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/LOCATION ) oZ CENSUS TRACT <br /> Owner's Name; Phone <br /> Address ,.. <br /> City.', ..� <br /> Contractor's Nam ,fir <br /> C� License # Phone <br /> TYPE OF-WORK.-(Check):. NEW WELL g7 DEEPEN '/- RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION -F/ PUMP REPAIR -/-7—PUMP REPLACEMENT 17 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK 'JSP SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED-USEff TYPE. OF WELL CONSTRUCTION SPECIFICATIONS <br /> •Industrial Cable Tool Dia. of Well Excavation �(J <br /> — -- <br /> Dom es•tic/private Drilled Dia. 'of Well Casing <br /> Domestic'/public Driven Gauge of Casing t; <br /> Irrigation Gravel. Pack Depth ofGrout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other �� Other Information <br /> Geophysical. - Surface Seal Installed 'B : s <br /> k <br /> PUMP INSTALLATION: .Contractor t <br /> - Type .of Pump H.P. <br /> PUMP REPLACEMENT: . /_7 State Work Done y ' <br /> PUMP REPAIR: / / State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter 1 <br /> Approximate .Depth <br /> Describe Material and Procedure i <br /> I hereby agree to comply with all. laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertainin_g�to_or. regu].ating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 ROUT NG AND A FIN SPECTION. <br /> SIGNED , TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE i FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY .. DATE J> 2_7 <br /> E H 1426 uwu_ A-7G � --- <br />