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SAN JOAQUIN" LOCAL HEALTH DISTRICT <br /> FOR OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> 11 Av Telephone : (209), 466-6781 <br /> IM APPLICATION FOR WELLLCONSTRUCTION OR PUMP PERMIT Permit No. � <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District:' <br /> JOB ADDRESS �Q�0 R,r/ �df! l! S/�d1jjV'1 CENSUS TRACT <br /> OwnerName Phone <br /> Address City <br /> i <br /> Contractor's Name "wa a S License , �� �Phane�1"' �/� <br /> �p � <br /> TYPE OF� WORK (Check) : NEW WELL A DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> _ _ t <br /> Other / / tj <br /> DISTANCE TO NEAREST: SEPTIC TANK6SEWER LINES :5_t,!9f PIT PRIVY y <br /> SEWAGE DISPOSFIELD�r CESSPOOL/SEEPAGE PIT BOTHER � <br /> PROPERTY LINES RIVATE DOMESTIC WELLS PUBLIC DOMESTIC WELL �• <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation `"CA <br /> Domestic/private Drilled Dia. of 'Well Casing d `� <br /> Domestic/public Driven Gauge of Casing <br /> �=•Grave;l:-:Pack— Depth of- Grout Seal <br /> Cathodic Protection Rotary ' � --"Type. of Grout k <br /> Disposal Other Other Information <br /> Geophysical Fes- Surface Seal Installed By:_� _ <br /> POMP INSTALLATION: Contractor <br /> !� Type of Pump H.P. <br /> PUMP REPLACEMENT: 7777t a—te Work Done <br /> PUMP `REPAIR: / / State4' ana <br /> '1 <br /> DES-TRUCTION OF WELL: Well Diame �%lLti Approximate Depth <br /> Describe MProcedure <br /> I� I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />; and tha 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED r [/� ►-�`� +i <br /> (b PLO P AN ON REVERSE SIDE) i <br /> FOR DE ARTMENT USE ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P E G OUT INSPECTION �y PHA I /F NAL INSPECTION <br /> JINSPECTION BY DATE INSPECTION BY DATE117-7 2M <br /> / <br /> i E H.11426 Rev.,; _.L4 <br /> _� - <br />