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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. )Z.//� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 3plication is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> toad/or install the work herein described. This application is made in compliance with San Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,,B ADDRESS/LOCATION / 5 ,)) 'S . L /r . J S CENSUS TRACT <br /> "mer is Name ( /-)/1 13 Uel Phone <br /> 77ddress !7 i J City <br /> )ntractor's Name ' ', ' ? /=it Y License # Phone- ' <br /> !PE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> [STANCE TO NEAREST: SEPTIC TANK n SEWER LINES <br /> _2_,}L 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 y <br /> Domestic/private Drilled Dia. of Well Casing L <br /> Domestic/public Driven Gauge of Casing % <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _� Rotary Type of Grout ( ;f ',_< ! ? <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv: <br /> —JMP INSTALLATION: Contractor <br /> Type of Pump H.Y. <br /> ^'JMP REPLACEMENT: / / State Work Done <br /> PMQP REPAIR: / / State Work Done <br /> I 'STRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .td 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 /> ' ?LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> tformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> OIGNED t i c' TITLE yr - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) is <br /> FOR DEPARTMENT USE ONLY �— <br /> PHASE I <br /> ?PLICATION ACCEPTED BY DATE <br /> bw)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 4SPECTION BY DATE INSPECTION BY DATE <br /> V <br /> c SI 14. 4 r__- 1 11 1177 41 <br />