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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£xOFFICE1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 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 Sun Joaquin LocalD District <br /> in compliance for a permit twith Sannct Joaqu .n <br /> t, and/or install the work herein described. This application <br /> County Ordinance No, ].862 and the Rules' and Regulations of the San Joaquin Local Health Disttict�. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone ' <br /> Owners Name eO <br /> -e City FIs A) <br /> Address �� <br /> License o, Phone g 0 <br /> Contractor's Name ivy; <br /> V <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ./7 RECONDITION DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR/? PUMP REPLACEMENT / <br /> Other / <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p <br /> E SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL- <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> le Tool Dia. of'Well Excavation <br /> Industrial Cab [1� <br /> Domestic/private Drilled Dia. of Well Casing 11 <br /> Domestic/public <br /> s Driven Gauge of Casing <br /> *. 'Gravel Pack Depth of Grout Seal <br /> Irrigation r s s <br /> Cathodic Protection Rotary Type o£ Grout <br /> '�, '-� Other Other Information' ' <br /> Disposal �. ""'�"�� : Surface Seal Installed'B <br /> .Geophysical . <br /> PUMP INSTALLATION:INSTALLATION: Cot actor <br /> _T.-ypeYof Pump <br /> PUMP REPLACEMENT: State Work Done. . <br /> PUMP­'.REPAIR <br /> } ISA <br /> / -State Work Done <br /> ' DES;TRUCTION OF WELL: Well.,Diameter+ _7 Approximate Depth <br /> ". Describe Material-and Pxocedure4 <br /> I hereby agree to comply wiall�laws and'`regulatibilS o£ the San Joaquin Local Health District <br /> th <br /> and to or_regulatiii�g well construction. Within FIFTEEN DAYS <br /> the State of California periai <br /> after completion of my work on a new we711, I will furnish the San Joaquin Local Health District s <br /> SWELL DRILLERS-REPORT-df the well and notify them before putting the -we13 in.use.... The above <br /> infortion is true to the-best-o£- my-.knowledge and belief. I WILL CALL FOR A GROUT INSPECT <br /> ma <br /> ,PRIOR TO GROU ING AND VI INSPECTION. TITLE <br /> SIGNED <br /> _ (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: P F NAL IN5PECTIO <br /> PHASE II-GROUT INSPECTION DATE <br /> INSPECTION BY <br /> DATE INSPECTION B <br /> I <br /> 'V 0 1 7r, RAv.. 1=74 <br />