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f <br /> f <br /> "EIIPU�S?.: <br /> A SAN JOAOUIN FOCAL HEALTH DTSTRCT <br /> �� OFF .1601 E. Hazelton Ave. , Stockton, Calif, / <br /> 4 <br /> Telephone : (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9_ <br /> I . . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued"f"7 <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 lin 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 ,r CENSUS TRACT <br /> Owner's Namer h c <br /> IJ Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License Z�3']zS__Phone ' y� �� ; 1 <br /> TYPE OF WORK (Check) : NEW.WELL / / DEEPEN%/ RECONDITION /�/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION �/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TDNEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �.i. <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i <br /> Industrial Cable Tool Dia, of Well Excavation <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 /> Disposal Other Other Information <br /> Geophysical . <br /> Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; 1,R7 State Work bone .# s�� <br /> PUMP .REPATR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with- all Jaws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction, Within FIFTEEN DAYS d <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-•b lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL 'INSPECTIO <br /> SIGNED TITLE <br /> (DRAW PLOT P ON REVERSE SIDE) F <br /> PHASE I <br /> if DEPARTMENT USE ONLY <br /> , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 0 SP TION PHASE III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />