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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4J ` <br /> THIS PERMIT EXPIRES 1 YEAR FROMSDATE 'ISSUED Date Issued 9p <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 / CENSUS TRACT <br /> Owner's Name Phono <br /> Address 4z City <br /> Contractor's Name -r License Phone g ,2,�7 <br /> TYPE OF WORK (Check): NEW WELL -/e'_7--1L'EPEN �'/� CONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION/REPAIR /_7 PUMP REPLACEMENT f7 <br /> Other / J -�- <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 DOMESTIC WELL ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1— able Tool Dia. of Well Excavation <br /> mastic/private Drilled Dia-. .of Well Casing <br /> Dome stic/public Driven Gauge of Casing <br /> Irrigation Gravel Page Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical Surface Seal Installed B :7Depth PUMP INSTALLATION: Contractor <br /> Type .of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxima <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.... .The 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 F'I ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' - - / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT PHASE III FINAL INSPECTIO <br /> ' <br /> 7ON <br /> BY e.. DATE INSPECTION BY DATE 3 <br />