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SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FOA OFFTtsE USE: 1601 E. Hazelton Ave. , Stockton, Calif . i <br /> Telephone: (209) 466-6781 Permit No. Q <br /> �—-- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> (Complete In Triplicate) rmit <br /> ;.- <br /> -.-ppa on is Hereby made to the San Joaquin Local <br /> lHcationDistrict <br /> made infor <br /> compliance twith SanuJoaqul0.y <br /> and/or install the work herein described. This appDistrict- <br /> County <br /> C <br /> County Ordinance No. 1862 andithe Rules and Regulations of San Joaquin Local Health Distr c ' <br /> F / CENSUS TRACT <br /> -JOB ADDRESS/LOCATION A.c�,Q_, Phone <br /> Owner's Name - � <br /> L City <br /> Address L l � <br /> _._License- _Phonez <br /> Contractor's Name _ - - - - - - - <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /_T ' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_T U <br /> r Other / / - <br /> � F <br /> SEWER LINES ' PIT PRIVY -r <br /> DISTANCE TO NEAREST: SEPTIC TANK - CESSPb6I /SEEPAGE'PIT OTHER <br /> - -- SEWAGE-DISPOSAL"FIELD` <br /> STIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTIONSPLIC ECIFICATIONS Z <br /> IN ED USE TYPE OF LL - <br /> w- Industrial able Tool Dia. of Well Excavation -- <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing J <br /> Do stic/public <br /> rrigation Gravel Pack Depth of Grout Seal ; <br /> Rotar Type of Grout <br /> I Cathodic Protection y Other Information -�— <br /> I Disposal Other <br /> Surface Seal Installed <br /> Geophysical B / <br /> i PUMP INSTALLATION: Contractor H.P . . <br /> Type of Pump <br /> �_PUmpfREPLACEMENT: .- / / State Work Done. _- <br /> PUMP REPAIR: / / State -Work-' ne <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 DAS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. Theabove <br /> information 1 true to the •t of my knowledge and belief_�I WILL C FOR GROUT INSPECTION <br /> IPRIOR TO GRD NG AN A F I SP CT ON, TITLE ' d <br /> SIGNED <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /J DATE <br /> I APPLICATION ACCEPTED BY jd✓jy// '� - <br /> ADDITIONAL COMMENTS: T pHpyR NAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY ATE <br /> INSPECTION BY DATE <br /> 1177 214 <br />