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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4664781 <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, fora 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 H altii Distric <br /> JOB ADDRESS/LOCATION <br /> Owner's Name <br /> Address <br /> J, ZACity <br /> Contractor's Name �{ License � ,� ?T Phonh*2 <br /> i <br /> TYPE OF WORK (Check) : N_EW;WELL,%/ DEEPEN/ / 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 <br /> PROPERTY LINE - PRIVATE DOMESTIC- WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL '% CONSTRUCTION SPECIFICATIONS r�r <br /> Industrial '" Cable Tool Dia, of Well Excavation W <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal W <br /> Cathodic Protection. Rotary Type of Grout ., _ r <br /> Disposal OtherOther Information w <br /> Geophysical Surface Seal Installed B : <br /> PUMPtINSTALLATIONI. Con.t.r.act-a x ` <br /> Type __ pmp - _ H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> i <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 Joaq 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- the well in use... The above <br /> information is ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROjjXTjFG AND A FINAL ?�P�CTION <br /> . <br /> SIGNED TITLE <br /> (DRAW PLO AN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: : . . <br /> PHASE II GROUT INSPECTION P,4ASE I/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPE'CTIOO.N� DATE ' <br /> E H 1426 upYr- , 1-74 b/77 2W ~ <br />