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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQF.OFFCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I ' <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 /> 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 ,?.3e CENSUS TRACT <br /> ! Phone <br /> Owner's Name a + L <br /> City 1Q <br /> Address <br /> S <br /> Contractor's Name License �� 75� Phone <br /> V , <br /> TYPE OF WORK (Check) : NEW WELL "/ I -DEEPEN I I RECONDITION :/ / DESTRUCTION / <br /> _:tin PpTNSTALLATION / / PUMP REPAIR ./ / PUMP REPLACEMENT <br /> j 0 th,r'"/ <br /> DISTANCE TO NEARES�TT ''SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .�wrPROPERTY ,L-LNE.i-=PRIVATE DOMESTIC WELL <br /> PUBLIC DOMESTIC WELL <br /> INTENDED.-USES TYPE OF .WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial -'_,• -�`-Gable-Tool Dia. of W11 Excavation <br /> Domestic/priva.te. Drilled Dia. of Well Casing <br /> e of Casing <br /> Domestic/public., Driven Gauge <br /> ck Depth of Grout Seal <br /> Irrigation% Gravel Pa <br /> Cathodic Protection _ Rotary Type of Grout <br /> Other Other Information ' <br /> Disposal <br /> Geophy.s� cal Surface Seal Installed B C <br /> a <br /> PUMP INSTALI;ATION: Contractor _ H.P. <br /> u - Type of Pump 7 <br /> PUMP REPLACEIAENT / State Work Done <br /> v <br /> PUMP ..REPAIR* State Work Done f <br /> I <br /> --7. Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> J" Describe Material and Procedure <br /> 3 F <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I and the State:of California_pertaining. <br /> to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a newiwell, I�wil1%furnish the San Joaquin Local Health District <br /> w WELL DRILLERS- REPORT of"'the c4ell-arid notifyy thembe- foresputting 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 <br /> PRIOR TO GROUTING D A FINAL INSPECTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I <br /> DATE/ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p SULI/Ff�DATE"'.7-/_/INSPCTION <br /> PHASE TI GROUT INSPECTION INSPECTION BY ' 7r <br /> 1 INSPECTION BY DATE <br /> p _ 214 <br />