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AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�_,_4yFICE USE: I60� E. Hazelton Ave. , Stockton, Calif. <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 liereby 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 Ordinance No. 1862 and the Rules and Regulations of the San ,Joaquin Local. Health District. � <br /> JOB ADDRESS/LOCATION k-41-y-d CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address ' d �1 City . ._ <br /> Contractor's Na G, License Phone <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /_ <br /> AL ; <br /> PUMP INSTLATION PUMP REPAIR/� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NFAREST: 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 \n�I <br /> Industrial Cable Tool Dia. of Well Excavation V) <br />_ Domestic/private Drilled Dia. of Weil 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 /> PUMP INSTALLATION: Contractor CSI�.,v <br /> Type of Pump ov,10 H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: <br /> / / 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 <br /> WELL DRILLERS REPORT of the well. and notify them before putting. the .weli. in.use.... The above <br /> information is true to-the-best-of my.. e e elief. I WILL CALL FORA GROUT INSPECTION , <br /> PRIOR TO GSWTING AND A FINAL INSPE <br /> SIGNED` LE <br /> (D W P T PLAN ON REV SE SIDE # <br /> R DEPARTMENT USE ONLY �! <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . �`-- <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> F. i; 1414 <br />