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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OFFICE USE: V11601 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 . rl-S-76 <br /> (Complete In Triplicate) 2-o4-- 9)30_00 <br /> Application is hereby :Wade to the San 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/L -CATION : CENSUS TRACT <br /> Owner's Name l', r ,� . Phone a -Jj <br /> �. � �_.•,... <br /> Address 0 D ,�,P City is <br /> Contractor's Name ��r^ License # Phone �aS <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/? RECONDITIO /'7 DESTRUCTION /_7 •� <br /> PUMP INSTALLATION / / PUMP REPAIR j .PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> fn <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private 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 Other Other Information j <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> i <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: . <br /> - State Work Done - <br /> PUMP ,REPAIR: State Work Done <br /> 7 / G <br /> DESTRUCTION OF WELL: Well Diameterroximate 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> 21�W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 6ADATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 0 Sf,94ffION PHASE I FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE y- <br /> LZ <br />