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_ - SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> FO ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -j�rtil� � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7XD-LLJiw <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Idealth 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 Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !� �-- 1� CENSUS TRACT <br /> Owner's' Name , Phone <br /> Addresszz <br /> City <br /> 3� �? <br /> Contractor's Name Lice3 # ' Phone?Clij <br /> TYPE OF WORK (Check): ..NEW WELL / --trtEPEN j RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR-/? PUMP REPLACEMENT f <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 able Tool Dia. of Well Excavation <br /> 7-13-o-me s tic/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 � - �j <br /> Disposal Other Other Information " <br /> 'Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump- H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done �:.. -....� <br /> I� PES-TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> t 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 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 them before putting.the..well. in.use.... The above <br /> information is true to- the-best-of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT D A F INSPECTI <br /> SIGNED — �_ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE — -- <br /> FOR DEPARTMENT USE ONLY <br /> IPPLICATION' ACCEFTED <br /> HASE I <br /> BY Jr DATE cT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA4 JXItFINAL INSPECTION <br /> 1 INSPECTION BY DATE INSPECTION BY & DATE <br /> E <br /> i • <br /> 1,/7 9M <br />