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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> `OF OFFICE USE: 1601 E. Hazelton Ave . , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <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 /> plication is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> iad/or install the work herein described. This application is made in compliance with San Joaqu: <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> .B ADDRESS/LOCATION j" ( �_ i��CJ /�� ,41 I�� CENSUS TRACT <br /> ner's Name �;'t. / i) �� (. I?Ui3L/�'%S Phone q1fZ/1J j/ <br /> adress le I City S,729CIrTc4H <br /> ntractor's Name // jj? e-, License # ' 61-0.2 Phone X-93Y7 <br /> r <br /> PE OF WORK (Check) : NEW WELL X7 DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> , STANCE TO NEAREST: SEPTIC TANK � a6_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> s <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 112 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout .itti'JCA'/TC <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> MP INSTALLATION: Contractor S <br /> Type of Pump H.P. <br /> " MP REPLACEMENT: / / State Work Done � <br /> i <br /> VITMP .REPAIR: / / State Work Done <br /> 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 /> .d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> --LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT_ INSPECTION <br /> RIOR TOq49UTINVW FINAL INSPECTION. <br /> 'TGNED » /' TITLE ''l�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'WASE I <br /> PLICATION ACCEPTED BY DATE '�� a 7/ <br /> IDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> SPECTION BYDATE ,: :. 77 INSPECTION BY. :T DATE <br />