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C AO vioSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE_ OFFICE USE:__" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 77-`/3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, Permit No. <br /> X3-7 <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED \ Date .Issued <br /> (Complete In Triplicate) <br /> Application is-hereby made to the San Joaquin Local Health District for a permit to construct <br /> r 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 /> 'f � <br /> j JOB_ ADDRESS/LOCATION 4-& ',�"/Ov4 441 r"CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> � v <br /> Address G.� City <br /> t ' License 46 37 J Phone <br /> kContractor s Name li <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 /> 1 <br /> Domestic/private R Drilled Dia. of Well Casing <br /> Domestic/public 3 Driven Gauge of Casing <br /> E Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ! Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ -Surface Seal"Ins-talled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:REPLACEMENT / / State Work 'Done <br /> PUMP .REPAIR: t /` State Work DoneA� <br /> Y l <br /> Approximate Depth <br /> DES•TRUCTIONOF WELL: Well Diameter pp <br /> Describe Material and Procedure <br /> k <br /> I hereby "agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> hand 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 a <br /> WELL DRILLERS REPORT of the well .and notify them before putting the .well in use: The above <br /> linformation is true to the.. best ofmy knoaaledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE ION. <br /> SIGNED ID TITLE <br /> ( W P OT PLAN ON ERSE SIDE)`; 1 <br /> .,FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ` p /F AL INSPECTION <br /> PHASE II GROUT• INSPECT DATE <br /> [INSPECTION-.BY -&-DATE ' ,�.LINSP:ECTION.BY. - - <br /> U Z7 - 2M <br /> ' a v <br />