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�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. fo <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <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. 1862 and the e d ations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOC CENSUS TRACT ' <br /> Owner's Name Phone ) <br /> Address City <br /> Contractor's Na <br /> License <br /> TYPE OF WORK (Check): NEW WELL ,1-7 DEEPEN /7 RECONDITION /? DESTRUCTION f7 <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 PTT OTHER i <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 Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic. Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical -" <br /> Surface Seal Installed 'B : i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . <br /> � State Work Done ,I <br /> PUMP '.REPATR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth f <br /> Describe Material and .Procedure . . . <br /> . r <br /> I hereby agree to comply with all laws and <br /> and the State of California pertaining regulations of the San Joaquin Local Health District <br /> 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 theta before putting the..well. in.use.... The above � <br /> information is true to- the•be'st of my_knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE T <br /> FORDEPARTMENT USE ONLY <br /> " <br /> APPLICATION ACCEPTED BY DATE ' ;� S <br /> ADDITIONAL COMMENTS:' <br /> PHASE TI GROUT INSPECTION PHM IAZOINAIINSPECTIO <br /> INSPECTION BY DATE INSPECTION BY TE i <br />