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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 'FFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d !� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 1:� l-7� <br /> ' (Complete In Triplicate) <br /> Application is 'hereby 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 Joaquie <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4:5 CENSUS TRACT <br /> Owner's NamePhone <br /> Address t,(J � City ' r <br /> Contractor's NameC_� �`<-cam /iC "'`�7 License # Phone Q. � J <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 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 Girout 'Seal- .-'- <br /> Cathodic Protection Rotary , , , Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal� Installed BY: <br /> PUMP INSTALLATION: Contractor�%d w <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: /� State Work Done Gu�•c� <br /> CPUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i I hereby agree to comply with all lams 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 to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FI INSPECTION. -- <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INS ECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - -- - -- - 1177 2M <br />