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SAN,,JOAQ'OIN LOCAL. HEALTH DISTRICT <br /> FOF :OFFICE USE: 1601 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 San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application ismade in compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of t San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION TRACT <br /> Owner's Name e4521L <br /> Ae j Phone 73 <br /> Address Cj Cit <br /> Contractor's Name License Phone <br /> w +A 1 <br /> TYPE OF WORK .(Check_) :_ NEW,WELL DEEPEN '/% RECONDITION /- DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK j SEWER :LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD 1.7-0 CESSPOOL/SEEPAGE PIT OTHER <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 _ uDK <br /> Domestic/private . Drilled Dia. of Well Casing �yti <br /> Domestic/public Driven Gauge. of Casing ---.,-J ____ <br /> Irrigation Gravel Pack Depth, of Grout Seal -"Q ' <br /> Cathodic Protection. _. Rotary _ Type of Grout _ <br /> Disposal Other Other-�Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pu H.P. <br /> PUi REPLACEMENT: . / / State _Work Done <br /> PUMA'-REPAIR: / / State -Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I-"'h&reby agree to comply with all laws-- and regulations- of the- San Joaquin Local Health District <br /> aiid 'the State of California pertaining to or reguiating.wel:l "construction. Within FIFTEEN DAYS <br />&f'�er completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well arncr'not'fy them-before putting the well in use. The above <br /> information ,is true to'f best of my no 1 a`g`e abelief. I WILL CALL FOR A GROUT INSPECTION <br />°RIOR TO GR TINAN A- INSPEC AI, <br /> SIGNED � ' TITLE <br /> 'yam (DRAW PLOT PLAN ON REV SE SIDE) _ <br /> OR D PARTMENT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED BY DATE -7-1.2217 / I� <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHA§F , INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE • <br />