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E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFO ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75/�J <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 Ordin nce No. 1862 and the-Rules and Regulations of the San Joaquin Local Health Distriet:.LL,- <br /> JOB ADDRESS ATIOI3 CENSUS TRACT <br /> Owner's NameLaI211 Phone ' <br /> Address Lr,& City �!Z&nv� <br /> Contractor's Name <br /> . License��a�1��=�•;�:Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INS ALLATION /7 PUMP`REPAIR /� PUMP REPLACEMENT % T <br /> Other %// I. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIIJES PIT PRIVY " <br /> SEWAGE DISPOSAL FIELD 4AMf CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '— <br /> PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> , �mestic/private Drilled Dia. of Well Casing„ <br /> Domestic/public Driven Gauge of Casing M� <br /> L.i l�rigation 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 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 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 /> - <br /> information is true to the best of my knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> PRIOR. TO G T G D A AL SPr6CTION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> APPLICATION' ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINA3, INSPECTIO <br /> INSPECTION BY DATE �� INSPECTION BY r DATE j <br />