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FOVOF USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �O <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date Issued II7D <br /> (Complete In Triplicate) <br />! Application is hereby made to the San Joaquin Local! Health Distract 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 <br /> CENSUS TRACT <br /> Owner's Name Aj <br /> L / Phone -� <br /> Address <br /> City 44O A/ <br /> Contractor's Name <br /> �✓ r License # �� Phone <br /> - r <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION I I DESTRUCTION /`7 _ <br /> PUMP INSTALLATION PUMP REPAIRI / <br /> REPZACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ►2 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE' PIT OTHER _ <br /> PROPERTY"I E=-'pRIVATE�DDI3E'SiTC�"C,7E L 7BLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL'S •. :; - C_ <br /> r CONSTRUCTION SPECIFICATIONS a' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing —� - j <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation g Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection Rotary T -r1 <br /> —Disposal Type of Grout <br /> Othex -. -0tk er"31.nform' ation <br /> Geophysical TJ I <br /> Surface Seal Installed B <br /> ti 4 <br /> PUMP INSTALLATION: Contractor '+ <br /> Type of Pump i. <br /> H.P. W <br /> PUMP REPLACEMENT: <br /> State Work Done � <br /> PUMP .REPAIR: Stt ate``t - <br /> `Work Done <br /> DESTRUCTION 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 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 GROUTING AND A GNAT INSPECTION. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -"7�, <br /> ADDITIONAL COMMENTS: ---- �. <br /> PHASE II GROUT INSPECTION P E /FIN D <br /> NSPECTION (� <br /> INSPECTION BY DATE INSPECTION BY ATE 7d <br />