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7 / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO � ! <br /> F .,OFFICE USE: 111...I�� 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 1 YEAR FROM DATE ISSUED Date Issued 2476 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Ilealth 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/LOCATIONr CENSUS TRACT <br /> Qwner'e Name c � Phone <br /> Address ) l �. `� City % 0 <br /> Contractor's Name ? License # O a�--Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/ RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION Ll PUMP REPAIR'/ 7 PUMP REPLACEMENT <br /> Other I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE r PRIVATE DOMESTIC WELL':_ PUBLIC DOMESTIC WELL . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �l�Cable Tool Ilia. of 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 Other Other Information ' ' <br />{ Geophysical Surface Seal Instal,led 'B <br /> s : <br /> f PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P <br /> PUMP REPLACEMENT: / / State Work Done e <br />,I PUMF .REPAIR: / / State Work Done <br /> . RES•TRUCTION 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 /> i 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 putting the-wellin 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 AN .-A FINAL INSACTION. <br /> SIGNED TITLE: D XL/ <br /> /f'Y <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E - DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE In=FINAL <br /> ' INSPECTION BY DATE INSPECTION BY DATE 4 - . <br />