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t SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F'd1R.OFFICE VU: i' 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 `7— <br /> ` (Complete In Triplicate) <br /> 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 /> County Ordinance No: 1862 and the Rules and Regulations of the Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d CENSUS T CT <br /> ( p27 <br /> Owner's Name % � Phone 0 " <br /> Address c� GG ! L City , ; <br /> Contractor's Name!✓ '�-e`T License 1���(�" Phone 1.. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /_7 DESTRUCTION ' <br /> PUMP INSTALLALIGN�, I PUMEAIEPAIR I I PUMP REPLACEMENT -7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t t <br /> T" SEWAGE•_DISPOSAL. FIEL]] CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBL-IC•DOMESTIC WELLT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia`. of Well Excavation <br /> 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 /> 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 -D-�-J 9--y--_ _ --_ Approximate Depth <br /> Describe Material anA 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 GROUTING A FINAL INSPECTION. <br /> SIGNED •" TITLES <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1;7 7: - 214 <br />