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J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T� � <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ] , <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local HelthDistrict made for compliancepermit <br /> to construct <br /> stall <br /> and/or in the work herein described. This application <br /> l County Ordinance No. 1862 and the!!Z�.Rules and Mations of the San Joaquin Loc HealthJc <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCAT <br /> Phone <br /> Owner's Name <br /> _ City r <br /> Address --- " ,.� <br /> t License ���50\� Phone %y-A _�`� <br /> Contractor's Name <br /> "DESTRUCTION <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN: / I RECONDITION / / / 1-7PUMP INSTLATION /�� REPAIR / / PUMP REPLACEMENT <br /> AL <br /> Other / / � • <br /> SE R LINES) PIT PRIVY LU <br /> DISTANCE TO NEAREST: SEPTIC TANK SSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISP SAL FIEL�/ WELL t PUBLIC DO WELL .rt <br /> PROPERTY LINE — PRIVATE DOMESTIC3WE CONSTRUCTION SPECIFICAT NS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation ' �r <br /> Drilled Dia. of Well Casing <br /> amestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Sea ' <br /> Type of Grout i <br /> Cathodic Protection �otar <br /> y <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMPI13STALLATION: ContractorCom' C <br /> H:P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done L <br /> } PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> F Describe Material and Procedure <br /> F <br /> l <br /> Ll ws and regulations of the 'San Joaquin Local Health District <br /> I hereby agree to comply with all la <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 J'oagiiin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the .wellin use. The above <br /> i orm ion is true to the be f my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,f+ <br /> PRI TO OUTING AND I INS ION. TITLE N" <br /> f ., iy .p bT PLANON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> Pell DATE '��-Z2 _ <br /> A PLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> - PHASE I GROUT INSPECT ON , --' PHASE III/FINAL INSPECTION <br /> INSPECTION BY <br /> DATE 2S .� INSPECTION BY �`� _ DATE <br /> � 7sX176E H 1426 Rev. J77 c s ► -- .. <br />