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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 2z- <br /> THIS PERMIT EXPIRES 1 YEAR� FROM DATE ISSUED Date Issued 3j 7 <br /> I <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. 1$62 and the Rules and Regulations of the San. Joaquin Local Health District. � <br /> JOB ADDRESS/LOCAD �� c,� + <br /> (,� � CENSUS TRACT <br /> Owner's Name <br /> T Phone { c:;; <br /> Address f <br /> 6 . 'City <br /> Contractor's Name <br /> License �����D� Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION AL / /-7_/ DESTRUCTION / _ <br /> PUMP INSTLATION• /�/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELI PUBLIC DOMESTIC WELL __ O <br /> INTENDED ,USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation d' <br /> Domestic/private Drilled Dia, of Well Casing _ U <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 f Other Information <br /> Geophysical Surface Seal Installed I3 <br /> PUMP INSTALLATION: Contractor fol <br /> Type of Pump H.ly. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-RE-PAIR: r - / / -.Stat-e--Work- Donee <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure T <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District a r <br /> and the State of California pertaining to or regulating well -construction. Within FIFTEEN DAYS I <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 puttingthewell 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 GR UTING ANDA Al, INSPECTION. <br /> SIGNED TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION / PHASE INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> R H 1426 Rav_ . i..7� <br /> 0,�l7 _ 2M I <br />