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SAN JOAQUIN LOCAL :HEALTH. DISTRICT <br /> FOF OFF-ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.U-000 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,,.. Date Issued /0-&- I <br /> (Complete In Triplicate) <br /> F 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. j <br /> JOB�ADDRESS/LOCATION % o CENSUS TRACT. _ <br /> Owner's Name /V Phone <br /> Address City t <br /> Contractor's Name <br /> (I' ` �icse�t4 Phone l <br /> i <br /> TYPE OF MORK (Check) : NEW WELL/L/�rEEPEN -/ / RECONDITION l-T DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other. / <br /> DISTANCE TO NEAREST: SEPTICITANK WER LINES PIT PRIVY <br /> i SEWAGE,DISPOSAL FIELD107'14- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _! Cable Tool Dia. of Well Excavation <br /> { mEstic/private Drilled Dia. of Well Casing <br /> r Domestic/public ° Driven Gauge of Casing <br /> irrigation A Gravel Pack Depth of Grout Seal ,S <br /> k Cathodic Protection it L,--RDtary Type of Grout <br /> Disposal, kt Other Other Information <br /> Geophysical Surface Seal Installed BF!- <br /> ' PUMP INSTALLATION: Contractor47 <br /> °`"— <br /> ► H. , <br /> Type of Pump . <br /> i <br /> E PUMP REPLACEMENT: / / State Work Done <br /> ++rte .;y1, is i .1 t: �✓ <br /> PUMP .REPAIR: `/ / State Work Done - _ t <br /> DESTRUCTION OF WELL: Well Diameter ; !:'°'Apptox ate bepth <br /> Describe Material and Procedure <br /> � I hereby agree to comply with all laws and regulations of the San J6aquin Local Health District <br /> and the State of California pertaining to or regulating well'consbruction. Within FIFTEEN DAYS <br /> , after completion of my work' on a new well, I will furnish the San Joaquin Local Health District a <br /> SWELL 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 GRO TING D A FINAL INSPECT <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE,)_. <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I' DATE ' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASEiII 41FINAL INSPECTION <br /> INSPECTION BX l ': --.r- DATE .� ! ., 7 * ,, INSEECTION, BY - _ DATE <br /> �, — <br /> ti' u 1� 7Fi 12— I-7G — _ <br />