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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 9,V477 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) . <br /> Application is hereby made to the San Joaquin Local Health District for a permitto 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. I <br /> JOB ADDRESS/LOCATION S CENSUS TRACT <br /> Owner's Name Phone $ - s <br /> .. �� - City-. 4��� . 1� <br /> Address <br /> Contractor's NameYt ��� .yCr,�. ,�y✓ -_- __ License Phone <br /> - <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION DESTRUCTION DESTRUCTION /_7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR f / PUMP REPLACEMENT f_1 <br /> = <br /> Other <br /> - f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE, PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q. <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/private j 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 p <br /> Geophysical Surface Seal Installed By:.__ <br /> j <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump -- H.P. <br /> 14 <br /> V` <br /> -_ �� <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP .REPAIR: . / / State Work Done <br /> DES-TRUCTION 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 /> I 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 FO.4rA GROUT INSPECTION <br /> PRIOR TO GROy_TINq AN NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �✓�Q DATE �O � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS; <br /> PHASE II OUT INSPECTION PHASE I I FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 11 <br /> 077 _ 2M <br /> U '1/.'7F n,.__ I -7A <br />