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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,KOFVICE USE: V.1601 E. Hazelton Ave. , Stockton, Calif. <br /> - <br /> Telephone: (209) 466--6781 ? X36 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6buft7 <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 e ulations of the S Joaquin Local Health- District. <br /> JOB AD`DRIECENSUS TRACTSS/LOCATION i <br /> Phone <br /> O"-er''�s Name � <br /> Address <br /> Contractor �� ��� Phone <br /> s Name <br /> sf <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTLATION 4 PUMP REPAIR -/—/ PUMP REPLACEMENT /� <br /> AL <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 SPECIFICATIONS <br /> lndus trial -- t. Cable Tool - Dia. of Well Excavation- <br /> Domestic/p ' Drilled, Dia. of Well Casing <br /> rzv�ate - '���, _ .. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation V Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installe <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 0, H.P. <br /> e <br /> PUMP REPLACEMENT: / / State Work -Done <br /> r <br /> PUMP .REPAIR: j j State Work,Done <br /> DESTRUCTION OF WELL: Well Diameter , r Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawsrand regulations of the San Joaquin Local. Health District <br /> and the State of California pertaining 'to or regulating well construction. Within FIFTEEN DAYS <br /> lafter completion of my work on a new weld., 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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GR,04TING AN F IjW AL W SP TION. <br /> SIGNED (DTITLE _ _ ��+► � � -- <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> r . <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ! ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHA II/ N INSPECTIO <br /> ZAjZ22_ <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> 1 77 % 2M <br />