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-SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. G 5 <br /> Telephone : (209) 46.676781 � 5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. IT 0 A <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 Ordi a ce No:486�2 and --he Rules and .Regulations of the San Joaquin Local Health District. <br /> 0 Ir <br /> JOB ADDRESS/LOCATION7� C,�S TRAGT � <br /> Owner's Name _ Phone �� <br /> Address � ���i:fdo a� -- City ��e <br /> Contractor's Name ,,.SSS ' � License o 'hones-.�F•�1"" <br /> TYPE OF WORK (Check) : NEW WELL /� PEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / RERA-IR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO 'NEAREST SEPTIC-TANK- -SEWER.-LINE-S-__ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP.00qn PKGE-'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 6' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> E�rrigation gavel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ,:`: Other Other Information <br /> Geophysical Surface Seal Installed By:: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P'. �O <br /> PUMP REPLACEMENT: / /< State Work Done <br /> PUMP .REPAIR: /; / State Work Done <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 District a <br /> WELL DRILLERS REPORT of the well ,and'notify them before puttingthewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AUD,,A FINAL NSPE <br /> SIGNEDTITLES <br /> �r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR'DEPARTMENT.,USE ONLY -- = Q <br /> 7 <br /> PHASE '1 ��� _ <br /> APPLICATION ACC1PTEb_BY17 <br /> ADDITIONAL COMMENTS: ,ae r te. <br /> PHASE II ROUT INSPECVION. PHASE III/FINAL INSPECTION <br /> INSPECTION BY g DATE INSPECTION BY � ', d DATE <br /> n,�77 2M <br /> C, E H 1426 Rev. - I-74 {_- _. <br />