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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. 77,M,&:3/Q <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued /s]) <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,,C CENSUS TRACT <br /> Owner's Name Phone <br /> Address 2. City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL/7/ DEEPEN '/—/ RECONDITION /7. DESTRUCTION /_ <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 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 We11'•Excavation' , <br /> Domestic/private Drilled Dia, of-Well.-Casing T <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 Sur_ face, Seal Installed By:. _ _,.•. ..._.. _•:• <br />�I PUMP INSTALLATION: Contractor _ _ — <br /> 4 <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work Done M <br /> PUMP .REPAIR: / f State Work Done <br /> DESTRUCTION 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 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 GR0j6T4LNG,4aD A FINAL INSPECTION. <br /> SIGNED TITLE 0*- rrz? ,,e <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J <br /> APPLICATION ACCEPTED BY C�/r� DATE �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P46_4jIII/F1jqAL INSPECTION <br /> INSPECTION BY DATE 41 INSPECTION BY DATE <br /> R P 1A9A T nom.. 1-7/. 117/ � •214 <br />