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JOAQUIN LOCAL HEALTH DISTRICT,- <br /> FOE OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f 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 /> Application is hereby made to the Snn Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application is made in compliance with Sam Joaqul <br /> II County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I. .SOB ADDRESS/LOCATION <br /> CENSUS TRACT--, <br /> .. Owner's Name t' <br /> Phone <br /> Address M / / / <br /> C City <br /> Contractor's Name 642Z-21, <br /> l � Z <br /> License 0 d Phone .3=.r ` <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN -/_-' RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION 0 PUMP REPAIR I / PUMP-REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 62Q ­ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT EITHER 1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Indus <br /> triali Cable Toot 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: f / „(;�•:a� <br /> PUMP INSTALLATION; Contractor <br /> Type of Pumpe H.P. <br /> _ 4 <br /> PUTT REPLACEMENT / / State Work Done <br /> PUMP 'REPAIR: /7 State Work Done <br /> DESTRUCTION 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 /> and 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 /> PRIOR TO GROUTINGAN A FINAL INSPE TION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION ; <br /> INSPECTION BY DATE INSPECTION BY DATE �- <br /> { <br /> ' I <br /> 7 <br /> PLATE 26 <br />