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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOP: OFFICE '`CJSE: 1601 E. Hazelton Ave. , ,Stockton, Calif. f% <br /> 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) <br /> Application ,is tereby made to 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_Ordi_nance No. .1862_ and the Rules and Regulations of the San Joaquin Local Health District. <br /> x <br /> l�f r r +_R Y. 3-Zoo-Z7 <br /> JOB ADDRESS/LOCATION© CENSUS TRACT <br /> Owner's Name Phone 99,E -to -._-- <br /> Address lilel City ' 4e <br /> Contractor's Name License �I, � L Phone <br /> I <br /> TYPE OF WORK (Check) : NEW WELL ] DEEPEN '/ RECONDITION /_/ DESTRUCTION /_7 , <br /> PUMP INSTALLA PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 4;-/D -(-SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALIFIELD —r-•--CESSPOOL/SEEPAGE-PIT OTHER <br /> PROPERTY LINE24�PRIVATE DOMESTIC WELD# PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 By: <br /> I` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . . <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 comply with all laws 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 notify them before putting the well in use. The above <br /> information is true t the b st "f y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G I ANVA FIN SP <br /> SIGNED TITLE E�,C <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I <br /> APPLICATION ACCEPTED` BY DATE �,-26.-7+ ` <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ,./FIN INSPECTION <br /> INSPECTION BY DATE - - INSPECTION BY DATE > <br />