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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1, OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. W <br /> Telephone: (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d <br /> THIS PERMIT EXPIRES 1- YEAR FROMDATEISSUED 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,1nstall the work herein described. , This application is made in compliance with San Joaquin <br /> County Ordinance No.. 1.862 and the Rules and Regulations of the San Joaquin. Local Health -District. <br /> JOB ADDRESS/LOCATION ,irle�r 'or O I �„r r"�G��irleICENSUS TRACT <br /> Owner's Name a ,,�� Phone <br /> .Address ' _ G To City <br /> Contractor t s Name Y['. d License # Phone 3711 O <br /> TYPE OF WORK (Check) : ' NEW WELL "/ / DEEPEN / / RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACE NT <br /> 0 then / r r► <br /> r <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGEJDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ( jCable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public # Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout n <br /> Disposal Other Other Information <br /> &-Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, . <br /> PUMP REPLACEMENT: State Work Done - - - <br /> r <br /> PIMP ..REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED -- TITLE Atg�c, ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR PEPARTMENT USE ONLY <br /> PHASE .I <br /> .APPLICATION ACCEPTED BY d4 � r� DATE ZI '7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT ;INSPECTION PHASW4I/FINO INSPECTION <br /> INSPECTION BY-,W- DATE z 0/7-7 INSPECTION BY� DATE /dL ,.� <br /> 46- <br /> 3R�- <br /> E H .1426 ev. � 1--74 <br />