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SAN JOAQUIN4!IOCAH HEALTH DISTRICT <br /> FOR.OFFICE USE: ` aV1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, ?7-7�Dz <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-/3:,7� <br /> ' (Complete In Triplicate) <br /> Application is tereby 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 and'. the Rules and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION x � CENSUS TRACT . <br /> Owner's Name Phone V;>7-� <br /> Address ; C=g City <br /> Contractor's Name License #ZiL/9�Phone <br /> IS <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP -REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO!NtkREST: SEpfiIC TANK -'. SEWER- LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 'CESSPOOL/SEEPAGE PIT _::7=OTHER At <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMEST_1-G-WBL•L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool"M a. of Well EXcavatiOn <br /> Domestic/private Drilled Dia. of Well Casing - fes, _/' <br /> D it�estic- ubl c Drivel ~ "Ga ge of-Casing <br /> Irrigation Gravel-Pack Depth of Grout Seal <br /> Cathodic Protection Rotary fir, "- Type of--Grout , <br /> �r <br /> ` r..Disposal Other ! Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 's <br /> Describe Material and Procedure <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 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO .GROU G D A FINAL PECTION. <br /> .7b, <br /> SIGNED ✓ TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ` FOR DEPARTMENT USE ONLY <br /> # PHASE I140, <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I F NAL INSPECTION <br /> INSPECTION By--. <br />