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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> v� <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 / CENSUS TRACT <br /> Owner's Name st r p,c� Phone <br /> Address City <br /> Contractor's Name _ ��� - -- License f�� Phone <br /> TYPE OF WORK (Check) : NEW WELL (5?, DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /!< PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK © - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT (JQ BOTHER <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 Z& <br /> X Domestic-/private Drilled Dia, of Well Casing • <br /> Domestic/public Driven Gauge of' Casing <br /> Irrigation Gravel Pack Depth of Grout Seal" <br /> Cathodic Protection RotaryType of Grout <br /> Disposal Other Other Information <br /> Geophysical �� Surface Seal Installed By: J A2 <br /> _�/G <br /> PUMP INSTALLATION: <br /> Contractor cE <br /> Type of Pump. H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR• ' <br /> StateW <br /> ork Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and.Procedure . <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 DAI�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 the well and notify them before putting the well in use.. The above <br /> information is to the best of m knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GR SP ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE f-// -„7 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY /„ .:. T— DATE /, - ��-.?tQ” INSPECTION BY -\� DATE ._ <br /> F N 7L9F n,.__ 1 '71. : i J77 om <br />