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SAN JOAQUIN LOCAL. HEALTH DISTRICT —7a <br /> L� •l� <br />" FOR�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 o <br /> E (Complete In Triplicate) <br /> ,1 <br /> Application is tereby 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>Jaaquin <br /> County Ordinance No. and the Rules and ReguI t.on of the San Joaquin Loca H al h Distr <br /> CENSUS TRACT <br /> JOB ADDRESS/ CAT10 <br /> Owner's Name Phone <br /> i. <br /> Address' City <br /> i �y <br /> Contractor's Name � � License Phoned�� <br /> TYPE OF WORK (Check) : - NEW WELL%/ DEEPEN /_/ RECONDITION /-7 � DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / .PUMP REPLACEMENT4 <br /> Other <br /> h 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of We11 Casing <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 Other Information <br /> Geophysical — Surface Seal Installed B <br /> PUMP INSTALLATION: Contracto' �_ <br /> --Ty pe � <br /> of Pump �P <br /> PUMP REPLACEMENT: . / / State Work Done <br /> t PUMP -'REPAIR: / / State Work Done <br /> " <br /> � nES.TRUCTION 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 /> l after completion ofmy 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 /> r information>is true- to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND NAL INSPECTI ` <br /> SIGNED - TITLE : <br /> DRAW 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 I IN INSPECTION <br /> INSPECTION BY +! DATE INSPECTION BY DATE <br /> x <br /> i <br /> 77 2rt <br /> ♦x S 1. a L .dS - <br />