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SAN JOAQUIN LOCAL HEALTH DISTRICT 7,,? <br /> FOP OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. �W4,- <br /> . . Telephone: (209) 466.-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> � <br /> THIS PERMIT-EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> � (Complete In Triplicate} <br /> Application is h r �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 /> Y 0 7O ' CENSUS TRACT <br /> ,. <br /> JOB ADDRESS/LOCAAON <br /> t Phone <br /> Owner's Name <br /> L City <br /> Address <br /> License Phone,-� ��� <br /> Contractor's Name •3• <br /> ` TYPE OF WORK ",(Check) ; NEW WELL DEEPEN / / - RECONDITION /_/ DESTRUCTION /rT <br /> PUMP INSTALLATION JXPUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES PTT PRIM' <br /> K <br /> SEWAGE DISPOSAL FIELD\ CESSPOOL1/SEEPAGEyPIT 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 /> G <br /> Domestic/private Drilled Dia. of Well Casing C <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .° r <br /> Gravel Pack Depth of Grout Seal C} O <br /> Cathodic Protection Rotary.. Type of gout <br /> Disposal Other-.. . Other Information <br /> Geophysical, - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Wor ` one <br /> PUMPREPAIR• / / State Work Done,�-b <br /> _ Approximate Depth <br /> f DESTRUCTION OF WELL: Well Diameter <br /> Describ� reeure �"". <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 /> ill furnish the San Joaquin Local Health District <br /> after completion of my work on a new well, I w <br /> WELL DRILLERS REPORT of the well and notify them before putting the well 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 AND A FIN NSPECTION.`/ <br /> t SIGNED �' TITLE '� -- <br /> (DRA LOT PL&AONREVERSE ST <br /> FOR DEPARTMENT USE 'ONLY <br /> PHASE I a <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE /FIN INSPECTION <br /> MPE-A- 1 G UT INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY DATES �� <br /> - . <br /> 14 -1426., Rev. - l-74/q- -() <br />