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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z ,1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 1 <br /> (Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anti/or instar 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 San Jodquin Local Health District. <br /> .FOB ADDRESS/LOCATIO !'</� �' � °� � CENSUS CT � <br /> Owner's Name ` ` Phone <br /> AddressS2 75 , <br /> s <br /> . � . � � r City . . . I <br /> Con tractar's Name.-- - Licensee-J hone- <br /> TYPE <br /> one TYPE OF WORK (Check): NEW WEI,I, /�EEPEN /7 RECONDITION /--7 DESTRUCTION /7 <br /> PVTINLA ATION / J PUMP REPAIR/? PUMP REPLACEMENT17 <br /> Other <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 0j WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing &r/ A <br /> Domestic/public Driven Gauge of Casing <br /> � <br /> Trig to r&h ; ..:� Gravel,-Pack ]� ��.- �.� Depth of Grout Seal <br /> Cathodic Protection_ Rotary'� Type of- Grout. <br /> Other Information <br /> Geophysical - r Setrace Seal Installed B <br /> k v 4i <br /> PUMP INSTALLATIONS Contr—armor ~ <br /> IT <br /> 'i <br /> ypd of-OPump H.P. <br /> PUMP REPLACEMENT: . / / 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 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 iay.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FI37AL INSPE, . <br /> SIGNED TITLE A . <br /> (DRAW PLOT. PLAN ON REVERSE..SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY °�, DATE �a . <br /> ADDITIONAL COMMENTS: i aK <br /> PHASE II GROUT INSPECTION YPMSIE T1,jjFjjNAL I SPE IO —f— <br /> INSPECTION BY DATE INSI�ECT N _ _. ATE = O <br /> F HV 1-Lyr nar <br />