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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR 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 SG/ -777 <br /> (Complete In Triplicate) <br /> S plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ip.,d/or install the work herein described. This application is made in compliance with San Joaquin <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1,_B ADDRESS/LOCATION L CENSUS TRACT <br /> `--zer's Name S �11 : c ( , Phone <br /> i7dress ✓ / C= ` R : iS �IX - City c r` <br /> itractor's Name ocwr� I,�tie� License # Phone <br /> 'E OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION 4�/ PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> )_>TANCE 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> — Irrigation- - Gravel Pack- - -Depth--of--Grout- Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> �. Geophysical Surface Seal Installed By: <br /> -iP INSTALLATION: Contractor 't f: _ C <br /> l <br /> Type of Pump z H.P. <br /> 'TrMP REPLACEMENT: / / State Work Done <br /> ZNP .REPAIR: / / State Work Done <br /> 1 •TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> tereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .ii the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> f-',L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> :ormation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> I'7OR TO GROUTING AND A FINAL INSPECTION. <br /> •TrNED CoA TITLE -e- � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'HASE I <br /> 'LICATION ACCEPTED BY DATE `-► 19 <br /> -")ITIONAL COMMENTS: <br /> PHASE II GRO SPECTION PHASE II/F AL .INSPECTION <br /> ;PECTION BY DATE INSPECTION BY DATE <br /> if77 _ 2M <br />