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FO :OFFICE USE; JOAQUIN LOCAL HEALTH DISTRIC4 f <br /> 16Hazelton Ave. , Stockton, Calif. <br /> Telephone: (200) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Ssy��o <br /> THIS PERMIT EXPIRES' l.YEAR FROM DATE '.ISSUED Date Issued'. <br /> (Complete In Triplicate) <br /> APPlic®tion is hereby made to the Sails Joaquin Local 11calth .District for a permit to construct <br /> and/or install the work herein described. This appllcation•ie made in compliance with Ssn J <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local He oaqui <br /> alth District. <br /> JOB ADDRESS/LOCATION <br /> C. .-.� CENSUS TRACT <br /> Owner's Name <br /> ft Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # <br /> TYPE OF WORK (Check): NEW WELL Jif DEEPENJ_7 �~ <br /> /`T RECONDITION f DESTRUCTION /7: <br /> PUMP INSTALLATION -�" PUMP REPAIR-/_7 PUMPREPLACEMd <br /> Other .�{_/ <br /> .DISTANCE TO NEAREST; SEPTIC 'TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISP05 FIELD __ <br /> INTENDED USE CESSPOOL/SEEPAGE PITOTHER <br /> PROPERTY LINE - PRIVATE WN- <br /> INTENDED WELL.' PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SP$GIFICATIONS <br /> rte: <br /> Indus tri a].• - t ' Cable Tool Dia. of Well Eiccavatian i <br /> � Domestic/private i Drflled Dia. of Well Casing I <br /> Domestic/public r Drilled <br /> IrrigationGauge of Casing <br /> -Gravel Pack' Depth of Grout_ Sear ` <br /> Cathodic Protection - I Rotary. Type of :Grout , <br /> Disposal { t <br /> Other . Other Information <br /> -Geophysical Surface Seal Installed 'B <br /> PUMP INS TION Contractor. <br /> Type .of .Pump 4 <br /> A eeC C� H.P. <br /> PUMP REPLACEMENT: Sate Work Done <br /> LTL, <br /> / / State Work Done <br /> §S,TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> ---�_ <br /> I hereby agree to comply with all• laws and regulations of the San Joaquin Local Health District <br /> and the State of California <br /> .pertaining to or regulating well"'constructiori. 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.uae..:: .The above' <br /> information is•true to the•best.•of "my..knnWledge and belief. <br /> PRIOR TOG ING AND FIN INSPECTION. I WILL CALL FORA GROUT INSPECTION <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-BY <br /> ADDITIONAL COMMENTSrDATB / 7 <br /> I. <br /> PHASE iI GROUT INSPECTION PHASE .TI FIN INSPECT ' <br /> INSPECTION BY DATA, INSPECTIN <br /> ON BY <br /> DATE <br />