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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FCG.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z-_Is <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 JoaquinE <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �y may. <br /> JOB ADDRESS/LOCATION /D d" / / CENSUS TRACT <br /> � Phone <br /> Owner's Name <br /> Address City <br /> d License ���Q � i <br /> Contractor's Name.. _ _ _ _Shone �'� <br /> YL <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /7 p <br /> PUMP INSTALLATION PUMP REPAIR /—/.--PUMP REPLACEMENT h <br /> Other -1/ / <br /> j <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 /> Industrial I Cable Tool , � Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/pdblic Driven Gauge of Casing <br /> Irrigation Gravel. Pack---Depth of .Grout Seal <br /> Cathodic Protection 1 Rotary _,Type of; Grout <br /> Disposal ;F !, -. Other,.,.,. `Other Information <br /> Geophysical `F W Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor�,zf <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: / / State Work- Done <br /> V of <br /> PUMP �REPAIR: / / State Work Done <br /> IE DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 DA S <br /> after completion of my work on a new well, I will furnish theiSan Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> E information is true to the best of my knowledge and belief: I WILL C FOR A GROUT INSPECTION <br /> I PRIOR TO G UTING ANDA INAL INSPECTION. <br /> SIGNED ! TITLE <br /> f f (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3-3� <br /> ADDITIONAL COMMENTS: t <br /> PHASE IIORQVT INSPECTION P S I I/FIN INSPECTION <br />(. INSPECTION BY DATE INSPECTION B <br /> 1177 ` 2M <br /> f F. 14 1G7h 12ay. 7_7L. . <br />