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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOV <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1-YEAR FROM DAM ISSUED <br /> Date Issued <br /> Application is hert (Complete In Triplicate) <br /> eby made to the San Joaquin Local <br /> and/or install the work herein described. This applicationDistmade in�c mpliancetwithSanq <br /> construct <br /> Jaa uir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loc <br /> • q al Health District. <br /> JOB ADDRESS/LOCATION <br /> fA.- WAL&fVA CENSUS TRACT ' <br /> Owner's Names <br /> Phone'U, <br /> Address <br /> Contractor's Name ,, City "" \ <br /> License 46 Phone �,��� <br /> TYPE OF WORK (Check) : NEW <br /> WELL / DEEPEN /_/ RECONDITION f_f DESTRUCTION /_]' �+1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /2'7— <br /> Other <br /> a r <br /> i DISTANCE TO NEAREST: SEPTIC 110& S <br /> EWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PRQPERTY LINE - HER <br /> PRIVATE DOMESTIC WELL OT <br /> INTENDED USE : TYPE OF WELL PUBLIC DOMESTICWELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private <br /> Cable Tool Dia. of Well Excavation C <br /> C � Drilled - <br /> Domestic/public t Dia. of Well Casing <br /> Irrigation <br /> Driven Gauge of Casing <br /> t.� � = Gravel Pack <br /> Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal y Other <br /> Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION Contractor <br /> Type of Pump <br /> 4 _ H.P. <br /> PUMP REPLACEMENT: . r " <br /> f�' State Work Done <br /> PUMP REPAIR: <br /> r / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 constru <br /> after completion ction. Within FIFTEEN DAYS <br /> 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 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 G OUTING AND <br /> SIGNED A FINAL INSPECTION. <br /> TITLE <br /> I <br /> PLOT PLAN ON REVERSE SDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY •!� <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE ,II /FIN INSPECTION <br /> INSPECTION BY INSPECTION BY• <br /> DATE <br /> �E Ft 2426 Rev. • 1_74 u/77 <br />