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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT e -mit No. ZZ-4v7 , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedy <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 Rules and Re ulations -of the an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION6;�) <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address / <br /> City <br /> Contractor's Name �✓� 'i <br /> .License #�� Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /% DESTRUCTION /_7 <br /> PUMP ._INSTALLATIONV/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Otherti/ <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/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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump V H.P. 11 j: <br /> PUMP REPLACEMENT: / / T State, Work Done4 ., <br /> PUMP REPAIR: / /- State Work-Done <br /> bES•TRUCTION 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 DAIS <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 use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL OR A GROUT INSPECTION <br /> PRIOR TO GgQUTING AN FINAL INSPECTION. <br /> SIGNED . <br /> - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMME <br /> P II GROUT INSPECTION PHA I/FIN NSPECTION <br /> INSPECTION BY ff DATE - INSPECTIONABY DATE r <br /> E R TG7h 177 ou <br />