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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> -- �-'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na <br /> 12 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued-� <br /> kA (Complete In Triplicate) <br /> ct <br /> Application is hereby made to the San Joaquin Local Health District..in <br /> a permit to ch San J <br /> and/or install <br /> 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 /> JOS ADDRESS/LOCATIONgo ) -6 T\ <br /> J P � O CENSUS TRACT <br /> Phone <br /> Owner's Name L I <br /> Address City �tT , <br /> . f <br /> Contractor's Name <br /> CA <br /> Licen�e # Q 2_ Phone <br /> • i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / RECONDITION / DESTRUCTION 7 <br /> PUMP INST CATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO•NEAREST: SEPTIC TANK _ SEWER LINESwPIT PRIVY <br />'t _SEWAGE DISPOSAL_FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> 'PROPERTY LINE - <br /> PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> lln <br /> Industrial` <br /> r Cabl-e. Tool Dia. of Wel]. Excavations _ <br /> �IzDomestic/private Drilled Dia, of Well Casing <br /> Domestic/pub-lic Driven Gauge of Casing <br /> Irrigation ' Gravel'Pack Depth of Grout Seal �U <br /> Cathodac.-Protection rRotary l Type of Grout <br /> Disposal Other ;`4�y� Other Information <br /> GeophysicalSurface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump ' <br /> PUMP REPLACEMENT: / /� �NState Work Done <br /> PUMP .REPAIR; /�F/ State Work Done <br /> DESTRUCTION SOF WELL: Well Diameter Approximate Depth' <br /> �J <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 anew well, I will furnish the San Joaquin Local Health District a <br /> r WELL DRILLERS REPORT of the well and notify them before putting the well iii 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 G UT G A FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - ® - INSPECTION BY DATE 9- <br /> i - { f Z <br />