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JOAQIJIN LOCAL HEALTH DISTRICT <br /> A�)F� _OFFICE USE: 160i-s . Hazelton Ave. , Stockton, Calix <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 /> .d/or install the work herein described. This application is made in compliance with San Joaquin <br /> ' •unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,B ADDRESS/LOCATION �� .Z J—U J �-�r u/'� / 2 /(/JLl h /(1 (� CENSUS TRACT <br /> 'merrs Name �� rt �; /1��/�ir L6taG� /V/< ZX- Phone f—L <br /> / l <br /> dress d l�i G�/ c/ /2 0 C.. City <br /> �ntractor�s Name�� ! r License #0��l1 P/" Phone _ �) /d / <br /> PE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 O <br /> _ Industrial Cable Tool Dia. of Well Excavation (J <br /> , ! <br /> Domestic/private _ Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S U <br /> Cathodic Protection _ Rotary Type of Grout <br /> _ Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> .,L'1,iP INSTALLATION: Contractor <br /> Type of Pump H.P. �} <br /> 'UNP REPLACEMENT: / / State Work Done <br /> ?UW '.REPAIR: / / State Work Done <br /> )ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IRIOR TO GROUTING AND A FINAL INSPECTION. ` <br /> SIGNED TITLE lti <br /> (PVAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1 DATE <br /> ADDITIONAL COMriENTS: <br /> PHAS GROUT INSPECTION PHA I FINAL INSPECTION <br /> INSPECTION BY DATE -� INSPECTION BY DATE -7 <br /> E H 1426 Rau_ 1-74 1-74 2M <br />