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SAN JOAQUIN LOCAL. HEALTH DISTRICT p � <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> d 7 7 , 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 D //-, <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 thework 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 Distr�ct. � <br /> JOB ADDRESS/LOCATION 5, CENSUS TRACT <br /> Owner's Name Ph one <br /> Address City ' <br /> l <br /> Contractor's Name License Ito? 9 Phone - /S <br /> F TY`PE_OF WORK, (Check) : lNEW WELL �_ DEEPEN / / RE ND DESTRLTCTIOIV /_7' <br /> -. PUMP INSTALLATION / / PUMP REPAIR./ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK CJSf SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT --- OTHER <br /> PROPERTY LINL50PRIVATE DOMESTIC WELL 1%2_' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well ExcavationX 22 r� ~ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 42 4_ & <br /> �[ Irrigation Gravel Pack Depth of Grout Sea U J' - <br /> 'Cathodic Protection Rotary Type of Grout ,rg,v_t <br /> Disp.osal Other Other Information <br /> Geophysical Surface Seal installed By <br /> * ( <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. '1 <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ;Describe Material and Procedure <br /> I hereby agree to complyr ;7f '-all laws-and-'regulations of the San Joaquin Local Health District <br /> I and the- State--of''Califdrnia' ..pertaining to or regulating well construction. Within FIFTEEN DAYS <br />' after completion of my work on'-a new well, I will furiiish/theJ San Joaquin Local Health District a <br /> I !WELL DRILLERS REPORT of the well and notify them before putting- the well in use. The above <br /> e informatidn is 'true to the b t my n ledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR .T R AN A FINA I PEC 0 j <br /> SIGNED TITLE <br /> OT PLAN ON REVERSE SIDE) <br /> F)a7 DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION-ACCEPTED BY EDAT <br /> ADDITIONAL' COMMENTS: <br /> PHASE II S TION P TI/FINAL INSPE�I � <br /> , INSPECTION BY DAT p - _ INSPECTION BY' DATE <br /> 1177 . <br />