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: SAN QUIN LOCAL HEALTH DISTRICT <br /> FOE OP€ie£-USE: 1601 E. nazelton 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 Z&-_Z4_-2r <br /> c{ '.(Completejn Triplicate) <br />-pplication is ,hereby made to the San Joaquin tocal Health District for a permit to construct <br />-nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules_ and <br /> �/u�l�atio �f_ tehe. San Joaquin Local Health District. <br /> OB ADDRESS/LOCATIONJ CENSUS TRACT <br />+wner's Name <br /> Phone <br />,ddress 5 7 40City <br /> 522 <br />:ontractor's Name 4 gicense 0 a9O81�one '/o3� <br />'YPE OF WORK (Check): NEW WELL / y` DEEPEN /-J RECONDITION /_T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / ., PUMP REPLACEMENT /7 <br /> Other/ 4C <br /> 0. oc <br />)ISTANCE TO NEAREST: SEPTIC TANK ', . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE'- PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICS <br /> jedustrial Gable Tool Dia. of Well Excavation rt <br /> Domestic/private 'Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> Irrigation __e_Gravpl Pack Depth, of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical : ', Surface Seal Installed By: <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: / ( h State Work Done <br /> �. <br /> BUMP .REPAIR: / / State Work Done " <br />)ESTRUCTION 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 ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a net; well, I•will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the'well and notify them before putting the w 1 in u The above <br /> information is true to the best of fey k9qwledge and belief. ' I WILL FOR GROUT ECTION <br />'RIORTO GRO G AND A IN NS CT IO <br /> SIGNED TITLE <br /> r D W P rT ON REVERSE SIDfr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /, <br /> APPLICATION ACCEPTED B$ �'� � /�r��. ) DATE [� �(C ,7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II QRQUT INSP ECTIQN PHASE III FINAL INSPECTION <br /> INSPECTION BY OfDATE INSPECTION BY DATE <br /> V7667& <br />