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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: E. Hazelton Ave. , Stockton, Calif. y <br /> Telephone: (209) 466-6781 -2 „ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6- ~7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d. This application is made in compliance with San Joaquin: <br /> and/or install the work herein describe <br /> nd Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules a <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION v <br /> �J,� Phone <br /> Owner's Name 1 U��' , <br /> ity <br /> Address <br /> License # Phone <br /> Contractor's Name � � • <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION , <br /> F PUMP INSTALLATION-,/ PUMP/ PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> AL <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 WELLCONSTRUCTDOMESTIC <br /> WELL <br /> ION TC <br /> INTENDED USE TYPE OF WELL <br /> M Industrial Cable Tool Dia.- of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �1 <br /> I 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 /> Surface Seal Installed B <br /> Geophysical <br /> PUMP INSTALLATION. Contractor H.P. <br /> Type of Pump /r <br /> s <br /> PUMP REPLACEMENT: / / State Work-Done <br /> ' PUMP .REPAIR: / <br /> State Work Done ' <br /> Ap�rpximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 3 I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> A <br /> and the State of California pertaining to or regulating sell 'construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> utting the. well in use. The above <br /> WELL DRILLERS REPORT of the well and notify them before p <br /> information- rue to the.best of y know-ledge' fid-belief:- I WILL CALL FOR. A..GRO.UT INSPECTION <br /> PRIOR TO GRO ING D A FINAJL I P ION. _ TITLE <br /> SIGNED <br /> ( 'RAW--P-LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE I DATE <br /> APPLICATION ACCEPTED BY ` <br /> ADDITIONAL COMMENTS: PHA / IN INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> r <br /> INSPECTION BY DATE <br />