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SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL BCON�ST'RRU�CTTIION OR PUMP ERMIT Permit No.�Q, /S l <br /> THIS PERMIT EXPIRES 1 YEAR FRO DATE ISSUED Date Issued ` -7 fl <br /> (Complete In Triplicate) <br /> Application is hereby made to. the San Joaquin Local Health District for a permit to construct i <br /> and/or install •the work herein described. This application is made in compliance with San Joaquin4 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o` �C � /®� ! _ CENSUS TRACT ' <br /> Phone <br /> Owner's Name <br /> -� � City <br /> Address - <br /> �����' ��3 <br /> Contractor's Name . i' License # Phone t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ I RECONDITION I / DESTRUCTION <br /> PUMP INSTALLATION %/ PUMP REPAIR / I PUMP REPLACEMENT 4 <br /> Other I I p <br /> DISTANCE TO NEAREST: SEPTZCfTANK SEWER LINES PIT PRIVY <br /> SEWAGE; DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -PROPERLY LINE - I'RIVt�TE DOMESTIC <br /> =-PUBLIC'DOMESTIC WELL <br /> INTENDED USE: TYPE. OF WELL_.. . <br /> CONS TRUCTION-SP.ECIF`ICATIONS r-----a--.; <br /> Industrial {� Cable Tool Dia. of Well Excavation <br /> Domestic/private `1 Drilled Dia. of Well Casing <br /> e of Casing <br /> Domestic/publicGauge.l Driven g g <br /> Irrigation ` I Gravel Pack Depth of Grout Seal. - _ <br /> Cathodic Protection it Rotary Type of Grout -- <br /> Other Information <br /> Disposal i{ Other -- <br /> Geophysical <br /> Surface Seal Installed n <br /> PUMP INSTALLATION: Contractor H.P. <br /> r Type of 'Pump <br /> PUMP REPLACEMENT: / / State Work Done T <br /> PUMP .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 thewell 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 FINAL INSPE TION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> f FOR 'DEPARTMENT USE ONLY <br /> fi PHASE IDATE C) <br /> i APPLICATION ACCEPTED BY i . c- _ <br /> k ADDITIONAL COMMENTS: i# PHASE Z I/ INAL INSPECTION <br /> PHASE IT GROUT INSPECTION <br /> INSPECTION BY 'I DATE INSPECTION BY DAT :<J -7� _ <br /> { - --- n/7 7 _ 2M <br />