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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF'rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local itealth 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/LOCATION17 CENSUS TRACT <br /> Owner's Name Phone <br /> Address City . , <br /> Contractor's Name c Licensee Phone,?4; ._ ?,97 <br /> TYPE OF WORK (Check): NEW WELL '/U---aEPEN �/7�CONDITION /7 DESTRUCTION j f <br /> PUMP INSTALLATION /tREPAIR'/� PUMP REPLACEMENT <br /> Other /% --- <br /> DISTANCE TO NEAREST: SEPTIC TANK 50. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial le Tool Dia. of Well Excavation 7 \rt <br /> mastic/private Drilled Dia: •of Well Casing 4 �y <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal CJ ; <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Sea] Installed B <br /> PUMP INSTALLATION: Contractor <br /> I <br /> Type .of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> I <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <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..well. in.use.,. .1'he above <br /> information is true to the-best . my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO IN D A II ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIB <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION' ACCEPTED BY �' DATE , - Z,3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT PHASE III FINAL INSPECTIO <br /> �v <br /> ON BY C DATE � INSPECTION BY DATE A172 , <br />