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L JOAQUIN LOCAL HEALTH DISC"RICT <br /> FOE.OFFICE US : ttt/// <br /> .. 160 . Hazelton Ave. , Stockton, Cal. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L6-3 a p <br /> - <br /> THIS PERMIT EXPIRES 1 YEAR FROM `DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> APPlicstion is hereby made to tha San Joaquin Local llcalthf District for a permit. to construct <br /> and/or install the work herein described,. This Application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules ad Regulations of the San Joaquin Local Health District'. <br /> JOB ADDRESS/LOCATION CENSU$-TRACT <br /> Owner's Name �:, �, .q� { <br /> Phare J <br /> Address City <br /> Contractor's Name . - License # 3 3 Phone <br /> ii <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /_/ RECO <br /> NDITION /� DESTRUCTION f f <br /> PUMP -INSTALLATION / / PUMP REPAIR .f PUMP REPLACEMENT 17 <br /> Other'. <br /> DISTANCE TO NEAREST: SEPTIC; TANK SEWER LINES PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PRflPER7CY 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 1Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP '.REPAIR: �] <br /> State Work Done <br /> 4�ell <br /> )ES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure. . <br /> I hereby agree to comply with all lams andregulations of the San Joaquin Local, Health District I <br /> and the State of California pertaining to or regulating well. "construction. Within FIFTEEN DAYS � <br /> if ter'Completion of my work on a new well, ;I will furnish the Safi Joaquin Local Health District a <br /> JELL DRILLERS REPORT of the wie11 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 /> 'RIOR 'TO GROUTING 'AND A F'INAI.l INSPECTION. <br />.3IGNED TITLE _ } <br /> .� <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE <br /> ?HASE 'I <br /> ePLICATION ACCEPTED BY <br />#DDITIONAL COMMENTS: DATE.' =5&, z r <br /> PHASE II I. SP TIO <br /> INSPECTION BY PHAS I FINAL INSPECTION,- <br /> INSPECTION <br /> DATE BY ^j E <br /> F <br /> E H 1426 <br />