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• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. h7-JY4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) 9 <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 Joaquin <br /> County Ordinance No. 1862 andtheRule and Regulations ofthjF�� San Joaquin Local Health District. <br /> JOB ADDRESS LOCAT �d�3 �-'CY <br /> / /� -•t� CENSUS TRACT <br /> Owner's Name Phone <br /> Address �G d City 6 <br /> r <br /> Contractor's Name License 444604 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <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 n <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 r Type. of Grout- <br /> Disposal Other Other Information <br /> Geophysical _ _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. y <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Thereby 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 CAI OR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND 'A F L INSPECTIO . <br /> SIGNED 6TITLE s <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 jiV/FINAje INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 77 <br /> 1177 2M j <br />