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4 <br /> . SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> 10F OFFICE USE: 1601 E. Hazelton Ave.,; Stockton, Calif. <br /> Telephone: (209)x.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application Ne'reby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein describe . This application is made in compliance with San Joaquin <br /> County Ordinance No.. 1862 and',-the Rul and Regulations a he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ION �.. CENSUS TRACT <br /> Owner's Name Phone <br /> 1 <br /> Address Ci )/,� <br /> Contractor's Nam ' License// 3��hoR�'�0y0r <br /> A <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIS' PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL%SEEPAGE,FIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL f <br /> INTENDED USE TYPE%.OF WELL,, f CONSTRUCTION SPECIFICATIONS 1r� <br /> Industrial t Cable Tool Dia, of Well Excavation ' • <br /> Domestic/private I. Drilled Dia. of Well Casing <br /> Domestic/publict 1 Driven Gauge of Casingr:A <br /> Irrigation Gravel Pack Depth of"Grout. Seal, 4 <br /> Cathodic Protection ? Rotary Type of Grout ' <br /> Disposal 4 • Other ; Other Information _ <br /> Geophysical 1. Surface Seal Installed By: " <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump � _HIP• ", <br /> / <br /> J <br /> PUMP REPLACEMENT: State Work Do ' <br />,wPUMP REPAIR.:- 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. us%. 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 A FINAO INSPECTION. <br /> SIGNED r TITLE � 3 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> k 5 - F FOR DEPARTMENT USE ONLY <br />' PHASE I <br /> APPLICATION ACCEPTED .BY CIS DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE �I /FINAL INSPEC ION <br /> kINSPECTION BY DATE INSPECTION BY !� ' - DATE <br /> If17_ 2M 4 <br />