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JOAQUIN LOCAL HEALTH DISTRIC <br /> F p, OFFICE USE: f_ 16G.—E. Hazelton Ave . Stockton Cal-._ , <br /> i <br /> Telephone :p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT e77� <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> a Pud <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work=herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION jCENSUS TRACT <br /> Owner's Name ' <br /> Jy Phone <br /> Address " f <br /> - c� C CityL�3 <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL ATION 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 r <br /> Industrial Cable Tool Dia. of Well Excavation r. <br /> Domestic/private Drilled Dia. of Well Casing <br /> �r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ii Other Other Information ! <br /> Ceophysical Surface Seal Installed By: <br /> P MP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 5 <br /> PUTT REPLACEMENT: /!' / State Work Done ` " <br /> PUMP .REPAIR: /L/ State Work Done <br /> )ES•TRUCTION OF WELL: Well Diameter <br /> --� -� Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyl.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 Distract a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to 61e best of my knowledge and belief. I WILL CALL FOR A GRO T INSPECTION ; <br /> 'RIOR TO G TING D A FIN � INSPECTION. <br /> SIGNED ti TITLE id <br /> " (D W PLOT PLAN ON REVERSE SIDE) <br /> i! FOR DEPARTMENT USE ONLY <br /> PHASE I I. <br /> APPLICATION ACCEPTED BY o rz "� DATE ;j'-2 -7 <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FI AL INSPECTION <br /> INSPECTION BY I� DATE / z INSPECTION BW <br /> !I ` <br /> i <br /> # 0 i4 r , 1177 _ <br /> ' <br />