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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , ..Stockton, Calif. <br /> Telephone: (209) 466-6781 �12ft) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> +, (Complete In Triplicate) <br /> Application is 'hereby made tojthe San Joaquin Local HealthDistrict <br /> furin ca permit to construJoaquin <br /> ct <br /> and/or install the work herein described. This application <br /> th Sa . <br /> County Ordinance-No. 1862 andrthe Rules and Regulations of the San Joaquin Local Health Dist#ct. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION0 <br /> e <br /> Phone <br /> Owner's Name r <br /> it City � '�--� <br /> Address G <br /> License P?Q Phone <br /> Contractor's Name <br /> TYPE OF WORK .(Check) : NEW WELL / DEEPEN -/ RECONDITION / / DESTRUCTION /7 <br /> PUMP ,INSTALLATION $e PUMP REPAIR / PUMP REPLACEMENT I�T <br /> Other 1 / / <br /> DISTANCE TO NEAREST: SEPTICITANK� � SEWER LINES PIT PRIVY <br /> SEWAGE. DISP SAL FIELD CESSP00L/SEEPAGE PIT OTHER \ <br /> PROPERTY IINEPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation O �y a <br /> Domestic/private: i Drilled Dia. of Well Casing `r <br /> Domestic/p <br /> ublic` 1 Driveri Gauge of Casing , <br /> Irrigations Gravel Pack Depth of Grout Seal - <br /> t c y <br /> Type <br /> of Grout _ per- •. <br /> Ca Protectiot . s Rotary <br /> — <br /> `df Other Other Information <br /> i Disposal. <br /> ' :Ge�ophysi.,cal = � Surface Seal Installed B - ��. = <br /> AS <br /> FUMP INSTALLkTION2 Gontx:actor <br /> Type of Pump ' <br /> PUMP REPLACEMENT: >._ . —, State Work Done <br /> / / <br /> � PUMP .REPAIR: <br /> 'State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> G Describe Material and Procedure <br /> I hereb Y agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> # <br /> and the State of California pertaining to or regulating weil'canstruction, Within FIFTEEN DAY <br /> my work on a new well, I <br /> after completion of will furnish the San Joaquin Local Health District a <br /> !-WELL DRILLERS REPORT o he well and notify them before putting the.,we11 in use. The above <br /> information is true o the ,best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU SPE ON. <br /> TITLE ztl <br /> } SIGNED (DRAW PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ` 7 <br /> i APPLICATION ACCEPTED- BY <br /> ADDITIONAL COMMENTS: !$S E I /FIN INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION B ATE <br /> INSPECTION BY .1 DATE — <br /> :: 2M <br /> c v IAlf, Do,.- 1-TA <br />