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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP.;OFF CE L*�E: 0.0 <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUFF 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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .c�{ <br /> .d • (i.-GL�t R CENSUS TRACT <br /> Owner"a Name, <br /> Phone , <br /> S <br /> Address n <br /> City •S Cf-�Q,ri <br /> Contractor's Name �% /� LicensePhoner3 <br /> F , <br /> TYPE OF WORK (Check) : NEW WELL / DEEPE9'17 RECONDITION /_" DESTRUCTIONS/f <br /> ,PUMP INSTALLATION / /- PUMP REPAIR PUMP REPLACEMENT /- <br /> Other — <br /> DISTANCE 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 r' CONSTRUCTION SPECIFICATIONS <br /> _Industrial , ' 4Cab,le-Too : - - - Dia:�of'�dell�Excavation <br /> Dotx�estic/private iDrilled Dia. of Well Casing <br /> Domestic/gUblic : Driven Gauge of Casing <br /> Irrigation _w__._ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal `Other Other Information " <br /> Geophysical' Surface Seal Installed By.-: <br /> PUMP:IINSTALLATION: Contractor <br /> Type of Pump <br /> H.P. L L� <br /> PUMP REPLACEMENT — <br /> / / State Work bone <br />,P�JNLP :REPAIR: State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Maierial and Procedure <br /> 1 <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 new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the •well and notify them before putting- the-well in use.... The above <br /> information i true to. the.b t-aflmy. owledge and belief. I WILL CALL 'FOR A GROUT INSPECTION <br />�'RIO�RT GR G� DAF INSPECT N.SIG <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> � . <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> � - <br /> APPLICATION ACCEPTED BY 1� DATE //-/ 2-."Ir <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY, DATE <br />