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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOB,,OFFIC SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> :f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -J/yo� <br /> P_ <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> U 1p L" ��'` 4 .� c_Aj ..f (Complete In Triplicate) <br /> Appnccat, io_h is,hereby made t'o 'the-San Joaquin Local Health District for a permit to construct <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 rm CENSUS TRACT QP6 - 'S-so <br /> Owner's Name �6 Phone ' <br /> Address ,, City C <br /> o <br /> Contractor's Name i cG < l License �Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION f_7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR /? PUMP REPLACEMENT f7 <br /> Other %/ . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ -OTHER I� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal, Other Other Information <br /> -Geophysical . Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> i <br /> PUMP REPLACEMENT / / State Work Done / <br /> PUMP F State Work Done <br /> DESTRUCTION OFWELL: Well Diameter Approximate Depth <br /> - �- - _ Describe Material and Procedure <br /> I hereby agree to comply with all lavas and regulations of the .San Joaquin Local Health District <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 rkotify them before putting.. the..well. in.use.... The above <br /> information is true to the.beste f- my edg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 3PRIOR R UTING AND A FIN SPE N. <br />`, SIGNE TITLE <br /> {DRAW PLT PLAN ON UEVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i APPLICATION' ACCEPTED BY �._..�._.� DATE <br /> ZtLi� <br /> ADDITIONAL COMMENTS: <br /> PHASE II WOUT INSPECTION PHASE III .FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> :w. <br />