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_ JOAQUIN LOCAL HEALTH DISTRICT <br /> OF OFFICE USE: , 160I^E. Hazelton Ave . , Stockton, Calm. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No� L� <br /> 7 S/f� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issu2d �7 <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Ind/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 an Rubes and/Regulations of the San Joaquin Local Health District. <br /> SOB ADDRESS/LOCATION CENSUS TRACT <br /> wner's Name Phone <br /> Address City <br /> contractor's Name �• License itr-f "Phone <br /> YPE OF WORK (Check) : NEW WELL / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION <br /> .. PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT <br /> Other <br /> _ISTANCE TO NEAREST: SEPTIC TANK Ur, SEWER LINES PIT PRIVY �1 <br /> SEWAGE DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINERIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing LL. <br /> ' Irrigation Gravel Pack Depth of Grout Sealer <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump —1 �%� H.P. <br /> "UMP REPLACEMENT: / / State Work Done <br /> 'PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter A 1 �� _ Approximate Depth Z,2�2 <br /> Describe Material and Procedure , <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> _:red 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 /> `TELL DRILLERS REPORThe well and notify them before putting the well in use. The above <br /> .reformation is t to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GROU AND F SP ION.. <br /> SIGNED TITLES --i <br /> (DRAW PTTT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY �} <br /> PHASE I <br /> OPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Y/IT/FIPAL INSPECTION <br /> :N8PECTION BY 7_2s-_?-- DATE �, INSPECTION DATE �i <br /> F. R lLL7Fi Rair. 1-7G <br /> 3/76 2m <br />