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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f� THIS PERMIT EXPIRES 1 YEAR <br /> FROM DATE ISSUED Date Issued <br /> �� (Complete In Triplicate) <br /> Application is here 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION f QB/ CENSUS TRACT j <br /> �• Phone7~ <br />'. Owner's Name <br /> City T� <br /> Address Zp <br /> 9 � � License # Phone �•_ <br /> Contractor's Name l <br /> TYPE OF WORK (Check) : NEW WELL-/, / DEEPEN I_I RECONDITION / / DESTRUCTION / T <br /> PUMP:INSTALLATION"/ / PUMP REPAIR PUMP REPLACEMENT— <br /> Others. <br /> DISTANCE TO NEAREST: SEPTIC TANK ""'. SEWER LINES -.. 'SPIT 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 7� <br /> Industrial t Cable Tool Dia. of Well Excavation �- <br /> Domestic/private E Drilled <br /> Dia. of Well Casing G <br /> Domestic/public Driven Gauge -of Casing \ <br /> Irrigations Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump \ <br /> PUMP REPLACEMENT: N17 State Work Done j (� <br /> PUMP REPAIR: / / ,' State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f 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 Californiapertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work, <br /> 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 thewell iri: use.., The;above <br /> information is true to thel=_best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING AND.A FI L INSPECTION. <br /> SIGNED TITLE <br /> Aj <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 00, <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> k ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE I _NSPECTION DATE/ - _7 7. <br /> I INSPECTION BY ATE INSPECTION BY G✓ <br /> b/77 2M. <br />