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SAN JOAQUIN LOCAL ..HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave.-, Stockton, Calif. <br /> Telephone : (209) 466-6781 A <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 hereb 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 _/� (� a(_;_al CENSUS TRACT <br /> Owner's Name : Phone " <br /> Address City <br /> License # hone '' <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / ; RECONDITION / / DESTRUCTION /� I <br /> PUMP INSTALLATION / ./ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK s'' SEWER LINES PIT PRIVY <br /> SEWAGE :I.II�•POSAL�F,IELD -CESSPOOL/SEEPAGE PIT OTHER f <br /> PROP.ERT-Y-•�N.E ---P -VA-T-F.,--DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool -;Dia, of Well Excavation <br /> l <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 /> DisposalOther -Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pi titp� o �:;.. H.P. a <br /> PUMP REPLACEMENT: / / State Work Done <br /> ti <br /> PUMP REPAIR: / State Work Done t4 f.1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth !. <br /> E <br /> E Describe Material and Procedure <br /> t 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 /> Cafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS ORT of the well and notify them before putting- the well in use. ,The above <br /> information s true to thet of my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO G OUTI AND A F AL1/INSP ON. -1 <br /> SIGNED TITLE <br /> L0 PLAN ON REVERSE STD <br /> DEPARTMENT USE ONLY <br /> nAL <br /> ION ACCEPTED BY DATE _77— <br /> COMMENTS: <br /> PHASE I G SRE ON PHASE II /FIN INSPECTIO <br /> INSPECTION BY D E INSPECTION BY DATE <br /> 0/77I <br /> F H IL96 Rav_ 1-7G <br />