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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE-USE 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued :n�'IZV <br /> (Complete In Triplicate) <br /> Application- is Aereby 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/LOCATIONf CENSUS TRACT <br /> Owner's Name PhoneFr ^ <br /> Address � _ , �X_ fir! City f SC A!y <br /> Contractor's Name A ��/ License ill Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEME4T1_7 _ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINESll-f PIT PRIVY <br /> SEWAGE DISPOSAL/ FIELD --- CESSPOOL/SEEPAGE PIT -- OTHER --- (� <br /> PROPERTY LINE'?Q PRIVATE DOMESTIC WELL/D �+ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,Industrial Cable Tool Dia, of Well Excavation za <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ 1A B P61 1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _V Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> a ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 5:a.te__Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ` r <br /> I hereby agree to .comply with all laws and regulations of the San Joaquin Local Health bistrict . <br /> and 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 /> information is true to the best of y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING A F A I ION. <br /> SIGNED - TITLE qfM <br /> (DRAW PLOT PLAN ON REVERSE SIDE) Li <br /> F FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY /� _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE, I <br /> GROUT#INSPECTION P E /FINAL NSPECTION <br /> INSPECTION BY 44t&PATE _7-2-7--"foo INSPECTION BY ATE Cr <br /> u r, � <br /> n ,. ► lav <br /> i �� 1 <br />