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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR HELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/ d1cJ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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. W92 and the 4ules and Regulations f the San -Joaquin Local Health District. <br /> 011's T ~� <br /> JOB ADDRESS/LOCATIO CENSUS TRACT - <br /> r �� �„ C;z <br /> Owner's Na // Phone <br /> Ik l <br /> Address Ci <br /> Contractor's Name License <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /�T RECONDITION J_7 DESTRUCTION /-7" <br /> PUMP INSTALLATION / I PUMP REPAIR PUMP REPLACEMENT 17 <br /> Other <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 SPECIFICATI .,/ <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . a 1 <br /> -(�- 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 /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENTca _ / / State Work Done <br /> PUMP ,.REPAIR: State Work Done <br /> DES;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..well. in.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 AND A FINAL INSPECTION. <br /> SIGNED ,- TITLE <br /> (DRAW PLOT PLAN ON.REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMHENT S: ��■`'"""' i � ry� � <br /> PHASE II GROUT INSPECTIONP II INAL INSPECTION <br /> INSPECTION BY DATE .. - ""`INSPECTION BY DATE - <br /> - - - <br /> 4 s <br />