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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> � <br /> County Ordinance Na. 1862 and the Rules . <br /> Regulations of the San Joaquin Local Health District. <br /> rzAt <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION p G <br /> ' Phone �.'k <br /> Owner's 'Named;f_ <br /> City <br /> Address t� / o <br /> iPhone <br /> CoFitractor's Name _ License # <br /> y 1 <br /> TYPE OF WORK (Check) : . NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK,/3o a/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL . Q <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELZ <br /> Industrial S Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing �l " <br /> Domestic/private <br /> Domestic/pub-tic Driven Gauge of Casing <br /> � <br /> �_ rrigation Gravel Pack Depth of Grout Sea <br /> � --'Il <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal • Other _ Other Information <br /> � • . .3 led B : <br /> _ Surface Seal Instal <br /> _Geophysical---- _4 - = <br /> PUMP ;NSTALI:ATION: Contractor _ H.P. <br /> - Type of Pump ` <br /> quMP 'REPLACEMENT: , /_/ i#S tate 'Work Done , <br /> IPUMP .REPAIR: State Work Done <br /> . , Approximate Depth _ <br /> :DES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> �y <br /> I'hereby agree}to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Statelof California 'pertaining to .or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of my work 'on a neyw' well, I will furnish the San Joaquin Local Health District a <br /> 'WELT. DRILLERS REPORT of the 'well and notify them before putting the wellin 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 GROUTING AND FINAL INSPECTION. TITLE .�� . <br /> SIGNE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY . k <br /> PHASE I.. <br /> ., �1 `/ ._ -. -- =.A•-,a: . DATE <br /> APPLICATION,-ACCEPTED BY G•�• - - - <br /> :ADDITIONAL COMMENTS: -'• <br /> PHASE IZ GROUT INSPECTION P I/ N INSPECT N <br /> DATE INSPECTION BY DATE <br /> `INSPECTION BY A/ <br /> 1 77 214 <br /> V 11 IATA Va i-7LL <br />