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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP, 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 DATE ISSUED Date -Issued <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 /> CENSUS TRACT ' <br /> JOB ,ADDRESS/LOCATION'. 1�0 59 T, '._ C1-'�n�+� �t. � � - -- •- - <br /> Owner's Name Phone <br /> 1 <br /> AndressSig rn.. City <br /> Contractor's Name )AJ License jt,22OZp Phone y ' <br /> TYPE OF WORK (Check) :; NEW WELL / / DEEPEN /T/ RECONDITION /_/ DESTRUCTION /7 <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 C� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL —PTJBLIC DOMESTIC WELL 'S <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 />'i Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> r Geophysical Surface Seal Installed B <br />` PUMP INSTALLATION: Contractor -7 ° —772-0 A -)ev <br /> s Type of Pump H.P. : <br /> 60 <br /> PUMP REPLACEMENT: / / State Work Done k{ <br /> PUMP REPAIR: % State Work Done x .r <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 Distract a <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> f information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D A FINAL NSPF.CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDj?!! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEJZ/7 <br /> ADDITIONAL COMMENTS: <br /> s PHASE II .GROUT INSPECTION. PHASE FINAL INSPECT N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M- <br />