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- // -SAN"JOAQUIN LOCAL HEALTH DISTRICT <br /> .. o� <br /> FOE;OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> € APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 21, 1� <br /> THIS _PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 /B D CENSUS TRACT <br /> ' <br /> 4 Phone <br /> Owner's Name o <br /> Address City . <br /> f/''1 <br /> 1 License # C 7fhone <br /> Contractor's Namei. <br /> jTYPE OF WORK (Check): NEW WELL /� DEEPEN /7 RECONDITION �P DESTRUCTION %I <br /> f PUMP INSTALLATION "/ / PUMP REPAIR � PUMP REPLACEMENT %f <br /> Other / r <br /> DISTANCE TO NEAREST: `SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE bOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial•• I Cable Tool Dia. of Well Excavation <br /> TIN <br /> Domestic/private t � Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> --- - Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' i Other Other Information <br /> Geophysical Surface Seal Ihstalled B7- <br /> PUMP <br /> iPUMP INSTALLATION: Conttactor H.P. <br /> Type I of Pump r.�✓ v�1-cy <br /> PUMP 'REPLACEMENT: / J State Work Done <br /> PUMP :REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 'Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Taws 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 <br /> District <br /> . .Th <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well. in.use,. above <br /> information is true to-the-best of- my.know edge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A. FINAL INSPECTI N. ITLE ,� o <br /> SIGNED Q_DtOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> ' PHASE. I DATE ' � R-� --- <br /> f APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: f <br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTIO <br /> } " DATE DATE // 2_1 <br /> INSPECTION BY <br /> INSPECTION BY <br />