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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601_ E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone:- (209)' 466-6781 <br /> ► <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L <br /> 3 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5- 7 <br /> (Complete In Triplicate) <br /> Application is Dere y 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 ,�� CENSUS TRACT <br /> Owner's Name �' - -- Phone 1)J`�7! <br /> Address [ , CityQ <br /> w � <br /> Contractor's Name I.L �J �_Q��j License #12C � Phone <br /> ` 1 <br /> r <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 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 /> Disposa•1 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 / AllL- <br /> PUMP :REPAIR: / / State Work Done <br /> 'DES-TRUCTION OF -WELL: Well Diameter Approximate Depth ' <br /> 6 Describe Material and Procedure <br /> � l hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> rand the State of California pertaining to or regulating we11 '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 /> jWELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> ainformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION,- <br /> PRIOR TO GROQ2JNG AND A FI AL IN PECTION. <br /> SIGNED _ r TITLE N <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASEI <br /> APPLICATION ACCEPTED BY DATE 2- , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION v �� SE FIN INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY DATE <br />