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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFICE USE: /eV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4. 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) 7-- � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to consorAct <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 /> JOB ADDRESS/LOCATION _' _t nc- _� -- d, E /��� bz c iv cCENSUS TRACT <br /> 7 <br /> Owner's Name l �� j ,� � '* ~� Phone { <br /> ^y � r <br /> Address _ f s �? `. A-7 r- 14L-:Lg:\1 City Lsci /.fJf <br /> Contractor's Name D ��i� �•,���� !�J License #V 77Phane 9 � <br /> f <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP RFP,&IRff REPAIR/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE"TO NEAREST, ' -SEPTIC'TANK--•' SEWER LINES PIT PRIVY <br /> SEWAGE-D,I-HP-SP -F-I-E 7D•-•---,,f--G-E-&SPOOL/-S-EE-P DIY---- OTHER o� <br /> PROPERTY LINE - PRIVATE%DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL f CONSTRUCTION SPECIFICATIONS µ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of,iWell Casing <br /> Domestic/public Driven '?$ Gauge of Casing <br /> Irrigation 1. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 0 Rotary Type ofiGroat <br /> Disposal �' �dther y1 Other Infor oration PT <br /> Geophysical 1. Surface -Seal- Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,,,,Type of Pump H.P. <br /> PUMP REPLACEMENT: ' *� <br /> / / State Work Done r <br /> PUMP .REPAIR: �, State Work Done-= <br /> of <br /> DESTRUCTION OF WELL:f Well Diameter Approximate Depth! <br /> t Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District j <br /> 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 puttingthe-well in use. The above <br /> information 'is true to the best of my knowledge and belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO G OUTING AN A FINAL INSPECTION. <br /> SIGNED _� TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /If-ZZ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E ITI/FINAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY�j�,/�/�. DATE ,7 .� h <br />