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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.� <br /> Telephone : (209) 466--6781. <br /> APPLICATION FOR WELL'zCONSTRUCTION OR PUMP PERMIT Permit No. 5� <br /> 1 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /,i)7 <br /> (Complete In Triplicate) " <br /> Application is reb made to the San Jba uin Local Health District for a <br /> Y q, permit to construct <br /> and/or install the work herein described. This apps cafion is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District;. <br /> JOB ADDRESS/LOCATION 9, G (/ CENSUS TRACT ' r <br /> Owner's Name Phone �_� <br /> Address h? City BSc .J <br /> Contractor's Name License X10-?Z 1/ Phone <br /> TYPE OF WORK (,,Check) : NEW WELL / / DEEPEN'/—/ RECONiiTIO L-7 DESTRUCTIO,'N <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> i Other <br /> DISTANCE TO NEAREST: , SEPTIC TANK SEWER LINES �, PIT PRIVY <br /> s ~SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIME -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICA_T_IONSjk <br /> Industrial Cable,-To Dia, of Well- Excavation <br /> Domestic4rivate `-Drilled Dia, of Well Casing <br /> Domestic/public Dzy_e� Gauge of Casing _,_ _ „ > i <br /> Irrigation Gravel Pack Depth of Grout Seal ,. <br /> Cathod.ie `Protection Rotary Type of Grout a ' <br /> Disposal; Other . .:, �-Ofher;'Information <br /> Geophysical Surface Seal Installed By: 4 <br /> f <br /> PUMP INSTALLATION: Contractor - <br /> Type,.of;Pump,":• :� � •� <br /> H.P. <br /> PUMP REPLACEMENT <br /> PUMP REPAIR.: S tate iWork\Done <br /> DES.TRUCTION_0F�WELL: Well Diameter Approximate .Depth r <br /> Describe Material and Procedure <br /> I hereby agreeto 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 GROUTIND A FINAL NSPE IUN. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE // /� 7 <br /> ADDITIONAL. COMMENTS: <br /> PHASE II qROUT INSPECTION PHA.S§,4jI/FINAT, INSPECTION <br /> INSPECTION BY DATE INSPECTION BYtV DATE <br /> 177 <br />