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SAN JOAQUIN LOCAL HEALTH DISTRICT` <br />r FO$:OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />I Telephone: (209) 466-6781, <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,�- <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 Joa <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local.Health Dietri <br />f <br />JOB ADDRESS/LOCATION SIG 7 T,1,5 17 42f CENSUS TRACT <br />Owner's Name <br />Address <br />Phone <br />r <br />City. <br />Contractor's Name _cei,z,� License # 'Z6 6�Z PhonegL- <br />TYPE OF WORK (Check): NEW WELL Q7 DEEPEN /7 RECONDITION /% DESTRUCTION /? <br />` PUMP INSTALLATION/ / PUMP REPAIR -7 PUMP REPLACEMENT / % <br />Other <br />DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br />`r 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 j Cable Tool'' Dia. of Well Excavation _ /G <br />Domestic/private i Drilled Dia. of Well Casing <br />Domestic/public <br />�' Driven Gauge of Casing <br />r Irrigation Gravel Pack Depth of Grout Seal <br />Cathodic Pr_otect__i`on Rotary Type of Grout <br />Disposal Other Other Information <br />Geophysical Surface Seal InstalledBv: <br />PUMP INSTALLATION: Contractor <br />Type of Pump H.P. <br />PUMP REPLACEMENT: / / State Work Done <br />PUMP .REPAIR: <br />_ _ _ /< / .State Work Done <br />DESTRUCTION OF -WELL: Well Diameter Approximate Depth <br />Describe Material and Procedure <br />i <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 />r after completion of my work on a new well, I will fui ish..the San Joaquin Local Health District <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 GROUTING ANR A FINAL_INSPECTION. <br />SIGNED TITLE <br />1 (DRAW PLOT PLAN ON REVERSE SID <br />E <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: 't <br />FOR DEPARTMENT USE ONLY <br />DATE <-/ 7-76. <br />PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br />INSPECTION BY DATE INSPECTION BY DATE r <br />