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SAN JOAQUIN LOCAL .HEALTH DISTRICT d <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. '"Op . '`•'' <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS. PERMIT EXPIRES :1 YEAR .FROM .DATE ISSUED Date Issued <br /> f <br /> (Complete In Triplicate) . �pOs_. �QCJr-0 <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 Joaquin <br /> 4 County Ordinance No. .1862 and the Rules and Regulations of the San'Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION 1,jz _1?(ik d Q� 1 CENSUS TRACT <br /> Owner's Name 0 � <br /> BB Phone ' g <br /> Address .- <br /> City i <br /> Contractor's Name � � fjf� _ <br /> � � Licensee/ Phare <br /> _ 1 <br /> TYPE OF WORK (Check) : NEW WELL /L-/--DEEPEN / / RECONDITION / / DESTRUCTION /-7 _ <br /> PUMP INSTALLATION NSTLATION /SUMP REPAIR f / PUMP REPLACEMENT 17 <br /> Other / / { <br /> DISTANCE TO NEAREST: SEPTIC :TANK EWER 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 t Cable Tool- -Dia..-of-We11-Excava-tion ---- <br /> t,-­-7-omestic/private t Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing d <br /> V Irrigation t Gravel Pack Depth`bf Grout Seal <br /> Cathodic Protection ' t Mary. ''Type of 'Grout ,tom <br /> Disposal ! Other Other Information <br /> Geophysical . Surface Seal Installed B <br /> PUMP INSTALLATION• ' <br /> Contractor <br /> Type of Pump E H.P. <br /> PUMP-;i-REPLACEMENT: / / -State.,Work-Done. : <br /> PUMP REPAIR:-' / /:` State Work Done <br /> �r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material, and Procedure <br /> r' <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 'construrction. '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`' ALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECT % <br /> SIGNED v TITLE. <br /> 2 ( RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR 'DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �_;j <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE,I-II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,d DATE <br /> .,.,.,E 11 1426 _Rev. � .2M _ <br />