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. � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 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 DA'Z'E ISSUED Date Issued I�% 7fl ! <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j/SS /trai ie CENSUS TRACT <br /> Owner's Names!/( Phone <br /> I <br /> Address Sao,. Citysr.�/� 1. _ <br /> Contractor's Name ��-� � Y /� r License 4� ?� 'hone <br /> I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN.!4 / RECONDITION / / DESTRUCTION <br /> -PUMP INSTALLATION / / _ PUMP. REPAIR "/ / PUMP REPLACEMENT <br /> -Other <br />'f DISTANCE TO NEAREST: SEPTIC'-TANK ,/5"0 SEWER LINES /6 PIT PRIVY" <br /> SEWAGE DISPOSAL FIELD -00- CESSPOOL/SEEPAGE PIT --49- OTHER <br /> PROPERTY LINVI 'PRIVATE DOMESTIC WELL A! PUBLIC DOMESTIC WELL _ <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 /> es ff/ ` <br /> Irrigation i�- Gravel Pack Depth of Grout Seal 6Z3 ` <br /> Cathodic Protection jC Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: e• <br /> PUMP-INSTALLATION: Contractor _ <br /> Type of Pump -- H.P. _/0 - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> � DES-TRUCTION 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'constructi.on. 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 thewell in use.. The above <br /> information is true to the bes of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN NSPECTION. <br /> SIGNED TITLE -- — <br /> (DRAW PLOT PLAN ON REVERSE SIDE)01 <br /> FOR DEPARTMENT USE ONLY <br /> \SE I <br /> '.ICATION ACCEPTED BY DATE <br /> ^ ONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASEtIII/FiNAL''INSPECTION �! Q <br /> ",ION BY DATE / /7, INSPECTION BY�/4/��,�p/ DATE I 1 l� <br /> 2M <br />