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• SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION DR PUMP PERMIT Permit No. � <br /> L!J THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7-; 7�. <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, Ord' ce No..._1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />,IOB�ADDSS�LOCATIOW "— CENSUS TRACT <br /> Owner's Named �. Phone St's <br /> Address L/ ^� �{�/ 'J City _ � 1 <br /> Contractor's Name � License ityPhonet? —�!C//f <br /> I <br /> i <br /> TYPE OF WORK (Check) : NEW WELL,, / / DEEPEN / RECONDITION /_7 DESTRUCTION /� 3 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other/ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ . SEWER,-,LINES PIT PRIVY <br /> SEWAGE DISPOSAL •FIELD , !"_ - .-CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE W 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 Well 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 /> GeophysicalSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1es,&> <br /> PUMP REPLACEMENT: / / State Work Done <br /> S <br /> j <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe MA.ter.ial 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 /> 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 putting the well 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 TOG UTING AND A_ FINAL I PE IO . <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 YI GROUT INSPECTION PHASE TJ11FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I/ V � i� <br />