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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 �f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �Z� <br /> (Complete In Triplicate) <br /> Application is hereby ma a to the San Joaquin Local Health District for a permit to construct' <br /> and/or install the work e ein described. This application is made in compliance with San Joaquin <br /> County Ordinanceo a he Rules and Regula ti ns f t San Joaquin Local Health, District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name one <br /> Address /lr City �O <br /> Contractor's Name License # Phone,9 _339 <br /> TYPE OF WORK (Ch'eck) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 LN <br /> .�., <br /> __PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /^T <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 /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation /$ <br /> `X Domestic/private Drilled Dia. of Well Casing -4 <br /> Domestic/public Driven Gauge of Casing, <br /> Irrigation Gravel Pack Depth .of Grout Seal, ,. <br /> Cathodic Protection v Rotary___ Type of Grout. <br /> Disposal _ .w t Other Other Information <br /> Geophysical. .Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.REPAIR: / / State,-,Work Done <br /> DESTRUCTION"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 bistrict <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, 1 wi:r1 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 CIROUTING AND A FINAL INSPECTION. <br /> SIGNED j TITLE1071 - <br /> (DRAW PLOT,PLAN-ON REVERSE. SIDE) . <br /> c <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY d3. DATE <br /> , ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY e DATE INSPECTION BY ZI DATE 11 <br /> U R _ " 2M <br /> R N 1G7fi D- 1-7/1 <br />