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Y SAN JOAQUIN LOCAL HEALTH DISTRICT 14hF[-, C) 1,12 <br /> FOe�ROF `ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 Per No• �7`�J J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> .; Date Issued <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin LocalHealthDistrict- for cpmplianceermit twithnSan'Joaquin <br /> and/or :install the work herein. described, This application <br /> Regulations, of the San Joaquin Local Health- District <br /> County Ordinance Na. 1862 and the Rules and <br /> • <br /> _ 0' U CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name r <br /> i <br /> City <br /> Address - <br /> p v G� <br /> i' License #jea �/ Phone <br /> Contractor's Name # <br /> l .t <br /> TYPE OF WORK (Check) : NEW WELMENT /_7L / DEEPEN/ / RECONDITION /_/ DESTRUCTION / <br />` PUMP INSTALLATION M PUMP REPAIR / PUMP REPLACEfi <br /> Other <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> CONSTRUCTION <br /> INTENDED USE TYPE OF WELL SPECIFICATIONS �. <br /> ation <br /> ' <br /> Dia. of Well Excav <br /> Industrial � Cable Tool <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> Driven Gauge of Casing <br /> Domesticfpublic ,� Depth of Grout Seal <br /> Irrigation 1. Gravel Pack P t <br /> Type of Grout <br /> Cathodic Protection I Rotary yP , N <br /> Other. Inf ormmation- �J <br /> Disposal .. � Other Surface^S,ea1 1A ailed By: <br /> Geophysical � .. _ <br /> Contractor >4 _�: , <br /> PUMP INSTALLATION: -V <br /> VyPe of Pump <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> PUMP REPAIR: / t/ State Work Done . , <br /> ' Approximate Depth' <br /> DES-TRUCTION OF WELL: well Diameter -- <br /> Describe Material and Procedure <br /> I hereby agree to comply <br /> with all laws and regulations of the San Joaquin Local Health District <br /> AYS <br /> and the State of California pertaining to or I reguwillkating fum shethecSantJoaquin.Local. Health District <br /> after completion of my work on a new well, { , above <br /> _ _ <br /> WELL DRILLERS REPORT of the well and owledhemand f�belief t�1 WILL CALL FOR AeGROUT eINSPECTION information �is--true=to=Ytlie"�b- st of my g <br /> PRIOR TO GROUTILM AND A F N INSPECTION. TITLE <br /> k SIGNED (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY �^�7 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> { ADDITIONAL COMMENTS: A PHASE I /FINAL INSPTIO p <br /> PHASE II GROUT INSPECTION INSPECTION BY DATEEC24 J <br /> INSPECTION BY DATE fN/ <br /> y I.1)4 1-7A <br />