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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 'OFFICE USE - -1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209)• 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO <br /> CENSUS TRACT <br /> r <br /> Owner's Name Phone , <br /> Address City <br /> Contractor's Name License 4f,2,&OZOhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP. INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / "- <br /> 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 Well Casing <br /> Domestic/public Driven Gaugejof Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal V <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> � _ \ n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP .REPAIR: / / State Work Done - � <br /> DESTRUCTION 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 /> 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 />?RIOR TO GR UTING AND A FINAL JNSeECTT.0N. <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 III FINAL INSPECTION <br /> INSPECTION BY DATE 64,lick INSPECTION BY DATE - - 7 <br /> E H 1426 Rwu_ 1-7G 1177 2M <br />