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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. j <br /> Telephone: (209) 466-6781 <br /> Ila- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> T THIS PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued 7-,2 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fot a permit to construct 3 <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 /> �tJ J7ys rV CENSUS TRACT <br /> JOB ADDRESS AOCATION p r�1 <br /> Owner's Name 6 <br /> Siea <br /> 1, ale - Oa +�/-) ._-Phone. <br /> Address /�/ riC1�S City ' ' <br /> Contractor's Name f -rte License #�-J s one ��k: 3 . <br /> TYPE OF WORK (Check)t NEW WELL/7 DEEPEN •/� RECONDITION �T DESTRUCTION . <br /> PUMP INSTALLATION '/ / PUMP REPAIR•/ PUMP REPLACEMENT f7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD OTHER PIT--,.,- OTHER r' <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 G <br /> Domestic/private Drilled Dia. of Well Casing c^ <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal4 <br /> Other Other Information r <br /> Geophysical Surface Seal Installed By: <br /> PUMP, INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> r <br /> -PUMP '.REPAIR: / / State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter E f/ Approxima a pth <br /> Descri Material and Procedure <br /> r c e_ f e fel <br /> I hereby agree to comply with all laks and regulations of the San Joaquin Local ealth District <br /> f and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 /> informatio tra to he-bes •of- my knowledge and belief. I WILL CALL 'F A GROUT INSPECTION <br /> PRIOR TO O TING AND CT ION. Ik <br /> SIGNED TITLE ' <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> 1; PHASE II GROUT IN CTION PHASE II FINAL INSPECTION G <br /> INSPECTION BY DATE INSPECTION BY � DATE <br />