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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6.781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NoX7 <br /> THIS PERMIT EXPIRES -1. YEAR FROM DATE ISSUED Date Issued f-2o_,?7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / `� �! CENSUS TRACT ' <br /> ev <br /> Owner's Name Phone6, C, <br /> Address rM 0=6EN& � d Cita' <br /> Contractor's Name �� cense V__f?4_16roKPhone <br /> i <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/ / RECONDITION / / DESTRUCTION /_ <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 Dia. of Well Casin <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 Jlnstalled B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. / <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth `l <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 pertainingo 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 AN A NAL INSPECTION. <br /> k SIGNED TITLE,; <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY L>' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE e /� INSPECTION BY _ DATE <br /> 2M <br /> V u 1A99 D- 1_7A <br />