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SAN JOAQUIN LOCAL .HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - B <br /> Telephone: (209) > <br /> 466-6781 � '�., <br /> e-luPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �M <br /> (Complete In Triplicate) <br /> Application is hereby made to t he San Joaquin Local Health District for a permit to, construct <br /> and/or install the work herei.ri­`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 L4 CENSUS TRACT <br /> Owner's Name �e%,v�� _ Phone <br /> Address - City <br /> �N11, ' <br /> Contractor's Name c License t Phone W <br /> LA <br /> TYPE OF WORK (Check) : NEW WELL f f DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION Zjq_ PUMP REPAIR / / I PUMP REPLACEMENT /? <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD-- CESSPOOL/SEEPAGE PITS= OTHER <br /> PROPERTY LIkYQ PRIVATE DOMESTIC WELL/AgaPUBLIC .DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ` - Dia. �of We11.Excavation "� <br /> ;Drilled ' _Dia. iof We11:."Casi'ng- <br /> Domestic/private <br /> f.. <br /> x- Domestic/public Driven n. Gauge of/Casing <br /> f a Irrigation + Gravel Pack Depth of Grout Sealey <br /> Cathodic Protection Rotary , Type of Gr6ut <br /> Disposal z Other Other-Information <br /> Geophysical Surface Seal Installed By: my'WAX <br /> PUMP INSTALLATION: Contractor <br /> L Type of Pump <br /> z <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMA' .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 /> jand 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 /> IWELL DRILLERS REPORT of -the well and notify them before putting the well in use. The above. <br /> ` information is true to thee knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A FI Na <br /> SIGNED TITLE <br /> :EDB <br /> (D PLOT PLAN ON REVERSE SIDE)OR DEPARTMENT USE ONLY <br /> PHASE I� APpLICATION ACCEPDATEkADDITIONAL COMMENP SP TI N PHAS I/FIN INSPECTIOINSPECTION BY rATE % INSPECTION B <br /> DATE <br /> 1177. <br /> n tz <br />