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SAN JOAQUIN LOCAL HEALTH DISTRICT i <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. <br /> THIS PERMIT <br /> EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ <br /> (Complete In Triplicate) <br /> II 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 /> i the San Joa County Ordinance No. 1862 and the Rules and Regulations of in Local Health District. <br /> /l <br /> 30B ADDRESS/LOCATION � �� 61G�.U�s � -�^ 1C.�V CENSUS TRACT <br /> Owner's Name /�i�`�' .� � Phone -� <br /> Address <br /> .. -2 b �. i"0 Q. City <br /> _ <br /> � A _ License #�gA Phone <br /> Contractor's Name �� . , <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /� <br /> PUMP;INSTALLATION / / 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 <br /> Cable Tool Dia. of Well Excavation <br /> Industrial <br /> Dia. of Well Casing <br /> Domestic/private Drilled <br /> Domestic/'public Driven Gauge of Casing <br /> ' Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other Other Information <br /> Disposal `� Surface Seal Installed B <br /> Geophysical <br /> I PUMP INSTALLATION: Contractor S H.P. <br /> Type_ of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> a <br /> PUMP .REPAIR: /V State Work Done <br /> F DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth _ <br /> Describe Material and Procedure <br /> t <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> k information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE ' <br /> SIGNED <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a DAI Z �� <br /> APPLICATION ACCEPTED BY <br /> poll <br /> ADDITIONAL COMMENTS: - PHASE I/FI INSPECTION p <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE l- 7 0 <br /> ' INSPECTION BY . LL ATE <br /> 0;Z111177 <br /> C <br /> 17*1j")A Doo 1-71L -_. <br />