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A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued �( 7 <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION / - V��� CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address <br /> r ��1 � --P City . <br /> c�' �y <br /> Contractor's Name ��0 <br /> License 4i�� 44" Phone <br /> a <br /> iITYPE OF,WORK (Check) : NEW WELL I I DEEPEN/ / RECONDITION / / DESTRUCTION /?,� <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLME <br /> ACENT �/ <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. -.PUBLIC DOMESTIC WELL <br /> INTENDED USE { .} # TYPE:`OF WELL-,- `, CONSTRUCTION SPECIFICATIONS <br /> 'Industrial ' Cable Tool - '-Dia -6f Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. , <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Other Other Information ' <br /> Geophysical Surface Seal Installed By- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ,PUMP REPLACEMENT: / / State Work Done <br /> IPUMP •.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> A Describe Material and Procedure <br /> kI hereby agree to comply with all. laws and .regulations of"tie'Sa"n""Joaquin Local Health District <br /> and the State of. California pertaining to or, regulating well construction. Within FIFTEEN DAYS <br /> after completion4of '.my work onid new well, I will furnish the San Joaquin Local Health District a <br /> FWELL DRILLERS REPORT of the well:, and notify them before putting the well' in use. The above <br /> information is trueto the'best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING `AND NALNSP CT N. <br /> TITLE <br /> SIGNED It <br /> (DRAW PLOT PLAN ON REVERSE SIDE} � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �' � <br /> APPLICATION ACCEPTED By `'-'! DATE <br /> €> ADDITIONAL COMMENTS: WPHAIPI ' ININSPECTII PHASE UT INSPECTION DATEINSPECTION BY DATE INSPECTION B <br />