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G� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. .. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued 1 P-7� <br /> (Complete In Triplicate) <br /> Aprlichtion is here y made to the Son 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 ,loa `' <br /> P quirt <br /> County Or No. 1862 and the Rales and Regulations of the San Joaquin Local Health District:, <br /> # JOB ADDRESS/LOCATION SUS TRACT <br /> Owner s NamePhone '3 <br /> r s <br /> 1 Address <br /> Contractor' Name If License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> 5 PUMP INSTALLATION -] / PUMP REPAIR �PUMP REPLACEMENT /7Other Ll ; <br /> II <br /> C DISTANCE TO NEAREST;: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> T . PROPERTYILINE - PRIVATE DOMESTIC WELL= _PUBLIC-DOMESTIC WELL <br /> INTENDED USE :j TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C Industrial jl Cable Tool. Dia. of Well Excavation <br /> ._ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casinj <br /> Irrigation t, I .- Gravel Pack Depth of GroutiSeal. <br /> Cathodic Protection ` Rotary Type of Grout <br /> i Disposal t f Other Other Information <br /> k <br /> Geophysical <br /> Surface Seal Installed "By: <br /> PUMP-INSTALLATION., "Contractor - <br /> Type of ',Pump <br /> H.P. 7 <br /> PUMP REPLACEMENT: . / State Work Done ti <br /> PUMP 'REPAIR:'- -State Work-Done�``J - <br /> E , <br /> DESTRUCTION OF WELL: WellDiameter i <br /> f 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�40rk 'on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS. REPORT_of fthe,weli and-notify them=b'efore--putting:the .well' in-use... .The above <br /> information is ue to the•b t of my.. wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />' PRIOR TO GRO A INSPECT <br /> SIGNED <br /> TITLE <br /> C DRAW PLOT PLAN ON REVERSE SIDE <br /> i� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> j <br />'iWLICATION' ACCEPTED BY -` DATE <br /> ADDITIONAL COMMENTS: <br /> j PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION`By ;I DATE INSPECTION BY DATE ,,L <br /> E H 1426 _ r <br /> Rev. <br />