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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 /> .ication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 17or install the work herein described. This application is made in compliance with San Joaquin <br /> inty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> —ADDRESS/LOCATIONT' <br /> of 14 jdtir�, _ /f/ n d CENSUS TRACT <br /> y r <br /> r's Name ¢ Qirc �pC$'q IV C- Phone <br /> ess <br /> city <br /> ractor's Name Ll J „ � License #/4 )J,� I Phone-?(, <br /> OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION )V PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> w.ANCE TO NEAREST: SEPTIC TANK nay SEWER LINES /S 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 I—a7l <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing al <br /> Irrigation Gravel Pack Depth of Grout Seal Sp i <br /> _ Cathodic Protection _� Rotary Type of Grout <br /> _Disposal Other Other Information V\ <br /> .. Geophysical Surface Seal Installed By: <br /> INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> REPLACEMENT: / / State Work Done C\ <br /> P .REPAIR: / / State Work Done <br /> RUCTION OF WELL: Well Diameter Approximate Depth Vj <br /> " Describe Material and Procedure <br /> reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> . the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> er completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ..rmation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> )R TO qATTK AND, A AL INSPMION. <br /> _TITLE----f'} - <br /> 14 DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> cE I <br /> ICATION ACCEPTED BY , DATE <br /> `LTIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ECTION BY DATE INSPECTION BY p, DATE <br />