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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, Calif. C5 <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�jthe 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. 1 <br /> E <br />' JOB ADDRESS/LOCATION 2696- M A &Oq CENSUS TRACT <br /> Owner's Name Phone g <br /> r <br /> Address 3 City .5 TOC,K TOIV <br /> Contractor's Name r, .� --.,License:4th_7� Phone S 7 <br /> TYPE OF WORK (Check) ; NEW WELL _1 DEEPEN_/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION. / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other'°/ / <br /> 6 E <br /> DISTANCE TO NEAREST: SEPTIC TANK ^/W SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC-DOMESTIC WELL S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation ; <br /> Domestic/private [ Drilled Dia. of Well Casing <br /> Domestic/public I ­�,,:Driven Gauge of Casing <br /> Irrigation �"t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotapy Type of Grout QE E <br /> Disposal72� "' rl <br /> rOthn r'er, Other Information <br /> - <br /> k Geophysical ;Ori Surface Seal Installed B O <br /> jk <br /> PUMP INSTALLATION: Contractor = <br /> Type of Pump. _ _ -- -..-- H.P. <br /> PUMP REPLACEMENT: / / - State Work Done <br /> . PUMP .REPAIR: / / State Work Done _ - <br /> ALIZ <br /> k DESTRUCTION OF WELL: We11;�Diameter AViNN Approximate Depth <br /> Describe Material .and-.Procedure . } <br /> r n, , <br /> I hereby agree to comply with all laws and regbrations of tie San Joaquin Local Health District <br /> and the State of California_- ertaining. to or regulating well•construction. Within FIFTEEN DA S <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 GALL FOR A GROUT INSPECTION <br /> PRIOR TO GRQWING AUD A NAL INS ION. <br /> SIGNED TITLE <br /> A (DRAW PLOT PLAN ON REVERSE SIDE) <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE /-/) - y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / "L, '] _ INSPECTION BY �% _ DATE '3 4--7P- <br /> : 1177 <br /> -.f -: 1177 2M <br /> R H 1 L 96 Rau- 1--7G <br />