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FOE OFFICE 1SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . SE_: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 0-/J <br /> ­)-7 <br /> f <br /> THIS PERMIT EXPIRES 1 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District;;", <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT x <br /> Owner's Name �� <br /> l Phone /67 <br /> Address ` <br /> City <br /> Contractor's- Name E <br /> License #� Z Phone�(� <br /> TYPE OF.,WORK (Check) : NEW .WELL DEEPEN J / RECONDITION_ .[ fes._DESTRUCTIONJ�7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT [� <br /> Other <br /> y <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 /> Industrial —al -Cable Tool Dia. of Weli Excavation <br /> Domestic/private Drilled Dia, of Well Casing M V <br /> Domestic/public Driven Gauge of Casing i��_ <br /> Irrigation Gravel Pack Depth of Grout Sa - "' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 40-041- 1 <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> PUMP `REPAIR: / J State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter <br /> - Approximate Depth...- <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <br /> and the State of California pertaining to or regulating well "constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish -the San Joaquin Local Health District ail <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.., The above i <br /> information is true to the best of my kn-oraledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO G OUTING AND"A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - L' <br /> ADDITIONAL COMMENTS: DATE �L2(2:$ <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY /' DATE <br />