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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -"OFFICE USE:/ 1601 E. HazeltonT Ave. , Stockton, Calif. �. 7 S, j <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ <br /> IT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> THIS PERM --�� <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 Ordinance No. 1$62 and the Rules and Regulations Of the Samoa inLocal Health District. <br /> in <br /> e CENSUS TRACT " <br /> JOB ADDRESS/LOCATION <br /> . t ► r Phone <br /> Owner s Name ,�t+ <br /> City <br /> Address <br /> License Phone 4E <br /> Contractor s Name Ale, + - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL g DEEPEN/ / RECONDITION -7 DESTRUCTION /? <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT I_T r�A <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 00 SEWER LINES PIT PRIVY OTHER � O <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE 'd PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable-Tool Dia. of Well Excavation Q <br /> Domestic/private <br /> Drilled Dia. of Well Casing <br /> � - Domestic/public Driven = . <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> IIItf� <br /> Cathodic Protection Rotary Type of Grout <br /> f <br /> p Other ,Information <br /> Disposal <br /> Other .Surface'Seal�Installed B ®-���'� <br /> p y <br /> , <br /> ro <br /> r. PUMP INSTALLATION: Contractor f _,.R..P.. <br /> Type of Pump <br /> - PUMP REPLACEMENT: . State Work Done ., <br /> PUMP .REPAIR: <br /> State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter . . <br /> Describe Material and.Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> hand 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 of well and notify them before putting the- well in use. The above <br /> information.-i tru he best�o„f my krrQwledge and belief. I WILL CALL FOR A GROIlINSPECTION <br /> k PRIOR TO GROUTI A INALIfINS.P,E,� if TITLE <br /> SIGNED <br /> t (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I -,T�� <br /> APPLICATION ACCEPTED BY F^ <br /> ' ADDITIONAL COMMENTS: PHASE III/FINAL INSPE N <br /> PHASE II GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> . _ 1477 2M <br /> U _1L1)A 'Dn11 1-7LL <br />