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tIIZ3 P;4 ls4d' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 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 EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 7 <br /> (Complete In Triplicate) <br /> Lpplication 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 Jo4quit <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION G D �O _ G� CENSUS TRACT <br /> wner's Nameoo Phone <br /> ddress �C� . /�a 7G �/� <br /> City <br /> ontractor's Name . J License # /,5971J"—Phone y- ?� <br /> YPE OF WORK (Check) : NEW WELL /-T DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /jW PUMP REPLACEMENT /_ <br /> Other <br /> ISTANCE 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> _X 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 Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> JMP INSTALLATION: Contractor } .� 4 j <br /> Type of Pump .*.c, H.P. <br /> JMP REPLACEMENT: / / State Work Done <br /> JMP .REPAIR: / / State Work Done Q� ' e--,d IC'eNt n <br /> :S•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> _e <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> :ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ;LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iformation is true to the best of knowle"e- d belief. I WILL CALL FOR A GROUT INSPECTION <br /> .IOR TO GROUTING AND A FINAL INSP I <br /> :GNED TITLE <br /> T= �1 <br /> ( PLAN ONVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> LASE I <br /> 'PLICATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE,.IIJIFINAL INSPECTION <br /> ISPECTION BY DATE INSPECTION BY DATE <br />