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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOR OFFICE USE: 1601' E. Hazelton Ave. , Stockton, <br /> Calif. # <br /> 1 " Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. /o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7" <br /> (Complete In Triplicate) <br /> Application is hereby made tol 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 and1the Rule ss and Regulations of the San Joaquin Local Health District. <br /> � <br /> JOB ADDRESS/LOCATION 4 � �' �' CENSUS TRACT <br /> Phone - 7 <br /> Owner's Name <br /> Address City `7 <br /> -- License it,/6.13 23 Phone) <br /> Contractor's Name `r <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN_/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other V-7 — J� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PUBLIC WELL <br /> PROPERTY LINE -- OMESTIC PRIVATE DOMESTIC WELL CONSTRUCTION DSPFCTFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> rIrrigation ' Gravel Pack Depth of Grout Seal <br /> Tpef Grout <br /> Cathodic Protection- ! Rotary Otherolnformation <br /> Disposal f Other <br /> Geophysical M Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor X) H.P. <br /> w Type of Pump <br /> j. <br /> PUMP REPLACEMENT• _ S tate._Ulo k pone _ ---- - - <br /> PUMP REPAIR: n State Work Dane <br /> DES-TRUCTION OF�WELL.: WeApproximate Depth <br /> 11 Diameter <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 Co or regulating well"construction. Within FIFTEEN DAYS <br /> f after completion of my work an a new well,, I wi11 furnish the San Joaquin Local Health District a <br /> . well in use.. The above <br /> WELL DRILLERS REPORT of the well and otify them before putting the <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 I INSPEC ON. <br /> TITLE <br /> SIGNED, Aid PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I " DATE/ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE IIT/FINAL INSPECTION <br /> w PHASE II�GROUT INSPECTION 00 DATE 12-0 <br /> PHASE <br /> INSPECTION BY DATE INSPECTION BY <br /> t. 7 7 _ 2M <br />