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SAN JOAQUIN LOCAL HEALTH DISTRICT W p <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: �( 5 <br /> ---- <br /> (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. G Q <br /> 7a '/_o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued ��- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local, Hedlth 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 /> -------------- <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> cs. �. . city <br /> Contractor's Name . <br /> i 1 - ,v <br /> I - License Phone <br /> I TYPE OF WORK (Check) : "'NEW-W•ELL / /_ DEEPEN <br /> RECONDITION /_/ DESTRUCTION 1-7 <br /> Other INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT ;PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEP,.AGE PIT <br /> PROPERTY LTN;E - PRIVATE DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> t Cable Tool Dia''- -of Well Excavation <br /> Domestic/private. E Drilled• <br /> �, r_._D?a.y of Well Casin <br /> <Domestic/.public �.�„� c_, "f Driven G <br /> Irrigation 4 g <br /> � �- ;,-auge ojf_Gasin <br /> � g <br /> ,� <br /> ;• z k ,, ,� ti �. ,y` y� Gravel Pack Depth of Grout Seal \ <br /> Gathodi.c Protectibn 1. Rotary ---Type of--Grout <br /> Other <br /> .Geophysical _ Other Information <br /> Surface Seal .Installed B : <br /> PUMP INSZ-ALU-T_.ON.:_._-Contxac.-t.or <br /> N Type of; Pump t -� <br /> PUMP REPLACEMENT: / / State Work Done <br /> F <br /> PUMP .REPAIR: ' <br /> / / State Work Done <br /> DES•TRUCTION -OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with 'all laws and regulations of the San JS <br /> oaqun 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 Toaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before <br /> information is true to the best of. my knowledge and belief�tzng the, well in use. The above <br /> ' I WILL CALL FO A GROUT INSPECTION <br />'BYOB TO GROUT' G AND A F AL INSPECTION. <br /> SIGNED �� <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br />'HASE I FOR DEPARTMENT USE ONLY <br /> 1PPLICATION ACCEPTED BYIU <br /> ADDITIONAL COMMENTS: DATE <br />=NSPECTTON BY <br /> PHASE I ROUT INSPECTION P SE. 1./FIN ' INSPECT ON <br /> DATE INSPECTION B + <br /> DATE <br /> .E H 1426 Rev. -7 ,» <br />