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SAN JOAQUIN LOCAL HEALTH DISTRICT 7 <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �� W �/ <br /> Telephone : (209) 466--6781 rf'_/r3 V`. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date lssuecQC � , ; <br /> (Complete In Triplicate) '+- 5b <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 Ordinance No. 1862 and the Rules. and Regulation of the San Joaquin Local. Health District. <br /> r� <br /> JOB ADDRESS/LOCATION`(() qIS . W rtr° r .5 EN5US TRACT <br /> Owner's Name _r Phone 2 <br /> City 'Al <br /> Address I <br /> Contractor's Name License ����f� Phone <br /> TYPE OF WORK (Check) :_ NEW _WELL.J / DEEP.EN.- / / RECONDITION DESTRUCTION <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/puUlic Driven Gauge of Casing <br /> iIrrigation ., Gravel Pack Depth of Grout Seal <br /> ' <br /> Cathodic Protection Rotary Type e of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> f PUMP INSTALLATION: Contractor lvz 9 4 IF H.P. <br /> Type of Pump -• - <br /> PUMP REPLACEMENT: /Y/ State Work Done 4A lZm p "Q ,�je 712 � <br /> PUMP .REPAI,R: + / / State Work Done <br /> •-� r4 <br /> kDES•TRUCTION OF WELL: Well Diameterti - Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and rfgulati.ons 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 thea San Joaquin Local Health District a <br /> k 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 C FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE 5I ) <br /> FOR DEPARTMENT USE ONLY �r <br /> PHASE I DATE <br /> APPLICATION ACCEPTEDBY <br /> ADDITIONAL COMMENTS: <br /> PHASE I PECTION PHAS II/FI INSPECTI N <br /> INSPECTION BY , TE INSPECTION B <br />