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SAN JOAQUIN LOCAL IiEALT[l DISTRICT r <br /> FOF OFFT E.-J1S[? . 1601 E. Hazelton Ave. , Stockton, Calif. �'�` <br /> Telephone: (209) 466-6781 _36 <br /> APPLICATION FOR WELL CONSTRUCTION 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 Ordinan a 18 2 a d R e d gulatiAons of he San Joaquin Local Health District. <br /> JOB ADDRESS LOCATI rf <br /> f c G d CENSUS TRACT <br /> Owner's Name Gal ] er Construction Phone 473-7900 <br /> Address 1308 Robinhood Dr. City Stockton <br /> V ID W 1 �u <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /7 RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION. /. PUMP REPAIR /7 PUMP REPLACEMENT f7 <br /> Other 2_7 <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 /> - Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing 7 m,s ZZ O C <br /> Irrigation Gravel Pack Depth of Grout Seal b`U•' <br /> Cathodic Protection XX Rotary 1Type of Grout' <br /> Disposal 7 Other Other Information <br /> Geophysical Surface Seal. Installed BY: 11 1 <br /> s <br /> PUMP INS'TALLATIONt , ' Contractor P <br /> Type of Pump jacurzi lop H.P. +� <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done <br /> ES•TRUCTION 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 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 pf- my knowleft) ad belief CALL FOR A•GROUT INSPECTION <br /> PRIOR TO O TING AND A SPECTION. a ry onsl:r <br /> SIGNED TITLE Agent <br /> di {DRAW PLOT PLAN ON REVERSE SIDE <br /> PRASE I R DEP'AR_T{}MENT USE ONLY <br /> APPLICATION ACCEPTED Y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE cY <br />