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r r. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE I7SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. <br /> I �� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z 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. 186 and the Rules and Regulations of the San J aquin Local Health District. ` <br /> JOB ADDRESS LOCATION CENSUS TRACT <br /> Owner's Name �'X - /�� _��" Phone <br /> Address City ' <br /> Contractor's Name License Phone Phone) <br /> TYPE OF WORK (Check) : NEW WELL "/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> ` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> k SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 'SPECIFICATIONS o(' <br /> ind'us'trial ----Gab3e Tool ---,---Dkaa.�-of We11-Rxcavation <br /> Domestic/private Drilled �_.Dia. of.-Wel.14 Casing <br /> Domestic/public given -Gauge of Casing <br /> 3 Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection + ; Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> I t <br /> 1 PUMP INSTALLATION: Contractor�~4� 0 � <br /> Type of.'Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Don <br /> i <br /> ' <br /> PUMP -.REPAIR: / / State Work Done <br /> IDES;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 /> - 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 G OUTING FI AL INSPE. TION. " <br /> SIGNED TITLE -- -� -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Xr�r <br /> , PHASE I � � - �.- <br /> APPLICATION ACCEPTED BY <br /> DATE 1lJ <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTIONS PHASE <br /> /FIN INSPECTION <br /> INSPECTION BY DATE "INSPECTION BY DATE , d' <br /> - J <br /> *-�R H <br /> 1,426 1-7 4. <br />