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;.�., .- <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , <br /> Stockton, Calif. <br /> FOFi'OFF�E USE: Telephone: (209) 466--6781 /J� 3�� <br /> Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued,3- <br /> ( (Complete In Triplicate) <br /> n is hereby made tolthe San Joaquin Local Health District forcompliancea permit to construct <br /> ApplicatioriJoaquin� <br /> and/or install the work herein described.. This application i <br /> . ations of the San Joaquin Local Health District <br /> county Ordinance No1862 and the Rules and gegul <br /> 1 <br /> cENsus TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone ' <br /> Owner's Name / 1 <br /> City.' ' <br /> Address <br /> License Phone <br /> Contractor's Name <br /> TYPE <br /> OF WORK. Check): NEW WELL / DEEPEN '/� RECONDITION PUT�EREPLACIOEMEI�T�I_T ti <br /> PUMP INSTALLATION �9` PUMP REPAIR1 . . ea <br /> Other / . / Tom. <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL"—. PM <br /> SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL t <br /> i Dia. of We11 Excavation <br /> I Industrial Cable Tool. C <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _._ Driven Gauge of Casing <br /> Irrigation Gravel Pack 'Depth of Grout Seal. <br /> e of Grout <br /> Cathodic Protection I� Rotary Tyner Information <br /> -�'""' ` <br /> Disposal Other Geophysical { <br /> Surface Seal. Installed 'B <br /> t <br /> PUMP INSTALLATION: Contractor S.P. <br /> t Type# of Pump <br /> PUMP REPLACEMENT / / State Work ne' <br /> ' PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> regu <br /> ating <br /> Within <br /> AYS <br /> ' and the State of California pertaining to or I willlfurnishethecSantJoaquin.Local Health <br /> after completion o£ my work on anew well, above <br /> ' WELL DRILLERS REPORT of the well and notify them befbeliefttil WILL CALL 'FOR A GROUTeINSPECTION <br /> or <br /> information is true to thefbest-of y g . <br /> PRIOR TO OUTING 'AND FINAL INSPECTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I r DATE J <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS&I IFINAL INSPECTION <br /> PHASE II GRO�TT IN ECTION INSPECTIONBY DAT - 7 <br /> INSPECTION BY DATE <br /> 214 <br />