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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � r <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. 1 /� <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 Joaquin" <br /> County Ordinance No. 18662 and the Rules and Regulations of the San' Joaquin Local Health District. <br /> ,c <br /> JOB ADDRESS/LOCATION / Lt-0 0 Aj � CENSUS TRACT <br /> Owner's Name ;raV=o 2 Y Phone,44� Z 3 <br /> Address <br /> Contractor's Name oz e License # Phone <br /> TYPE OF WORK (Check) : NEW WEL EEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSS ALLATION / / PUMP REPAIR / f PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK �C'' 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 /> ! <br /> Domestic/private Drilled Dia, of Well Casing - <br /> Domestic/public Driven Gauge of Casing 9" <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 a <br /> Type of Pump- H.P. <br /> PUMP REPLACEMENT: / / State Work Done n <br /> PUMP .REPAIR: / / State Work Done <br />➢ES-TRUCTION OF WELL: Well Diameter Z,45 Approximate Depth � <br /> Describe Material and Procedure _ � �— re,;, --j <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 DAY'S <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 w <br /> PRIOR TO GjkOJJTI4,GIAND A FI AL I CTION. <br /> SIGNED TITLE - &v 'OL-)<e <br /> ? ( P <br /> AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: /d <br /> PHASE II T P&SPRdTfOR IV /PHASE T I/ NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 6177 7M <br />