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F_ - JOAQUIN "LOCAL HEALTH.DISTRICT <br /> FOE OFFICE USE: 1601 .. Hazelton Ave., Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��_�N 90 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,9_&_ <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 <br /> /the Rules and Regulations <br /> of -th_e San Joaquin Local Health District. <br /> JOB ADDRESS/LOON' J� �ti�t/YW �— CENSUS TRACT e <br /> Owner's Name / Phone <br /> Address !/ �� City <br /> Contractor's Name License II,2j!?jQfj3Phone 15Z2-LP31 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /�' RECONDITION /_� DESTRUCTION % f <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Others / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY L <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER PC <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL — <br /> INTENDED USE , ' TYPE' OF WELL , t CONSTRUCTION SPECIFICAT ONS <br /> Industrial " ,Cable Tool Dia. of Well Excavation <br /> Domestic/private . Drilled Dia. of Well Casing ( <br /> Domestic/public Driven Gauge of. Casing IZ Cy.C� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection rotary Type of Grout' <br /> Disposal Other Other Information (b <br /> Geophysical �— Surface Seal Instal' ed By- <br /> PUMP <br /> :PUMP INSTALLATION: Contractot <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f_1 State.Work Done <br /> PUMP .REPAIR: / / State,'Work Done . <br /> 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 $an 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 WIL L FO GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FIN INSPECT <br /> SIGNEDTITLE '( <br /> DRAW'PLO PLAN-ON REVERSE S ) �• , <br /> FORj9EPARTNENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY '�l! .� '— / : �^ n DATE <br /> ADDITIONAL COMMENTS: <br /> P E I OUOU—�EC I N PHASE III/FINAL INSPECTION <br /> INSPECTION BY w DATE INSPECTION BY 0. DATE _ <br /> 3/7" <br />