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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi;OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 �-6atip <br /> I <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 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 /> .TOB ADDRESS/LOCATION CENSUS TRACT <br />. Owner's Name <br /> Phone <br /> Address ul g3 <br /> City ' DiLl <br /> Contractor's Name <br /> License V Phone <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN '/? RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION �I PUMP REPAIR REPLACEMENT 17 <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 t� <br /> Industrial Cable Tool Dia. of Well' ExcavationDomestic/ V�j <br /> Domestic/private �_ Drilled Dia, of Well Casing <br /> Irrigation <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pry Type of Grout <br /> otection Rotary �I <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed B <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: W State Work Done <br /> i <br /> PUMP 'REPAIR: State Work Done <br /> LES•TRUCTION OF WELL: Well Diameter <br /> 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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the .w' 11 in.use.... The above <br /> information is true to the-best of my-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION 4 <br />'RIOR TO GRO ING 'AND A FINAL NSPECTION. s <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY } <br /> �{ <br /> APP CATION ACCEPTED BY DATE /d2 '4/ 'T, - <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i <br /> INSPECTION BY _ DATE INSPECTION BY DATE, � <br /> E H '1476 na., 1_'7 r ._ <br />