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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: <br /> 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 71 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquinr <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION IsT p CENSUS TRACT <br /> 41 Owner's Name Q p.� 7 Phone <br /> a Q r � City <br /> Address _ <br /> Contractor's Name ';.. License # Phoneme <br /> TYPE OF WORK (Check) : NEW WELL / ./ / /DEEPEN'/ / RECONDITION / DESTRUCTION /rT <br /> PUMP INSTALLATIONf- PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE\TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , ?¢ ' •, 1 <br /> .� <br /> _,< ---R-SEWAGE-DISPOSAL-FIEDD�---� '�""�CESSPOOL[SEEPAGE`PIT-�' - OTHER <br /> Y y •_, <br /> PROPERTY LINE - PRIVATE DOMESTIC- ELL PUBLIC DOMESTIC WELL <br /> INTENDED""USE TYPE OF WELL f y -CONSTRUCTION SPECIFICATIONS <br /> Industria].'+ Cable Tool Dia: of�Well 'Excavation <br /> Domestic/:private Drilled Dia:-of- Well -Casing ' <br /> .-•; * •. <br /> Domesticpublic Driven Gauge of Casing <br /> Irrigati'6n,, Gravel Pack Depth of Grout,-Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disgosa_�" 5 <br /> -.'Other Information " <br /> � Other <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: <br /> 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I A/ DATE <br /> APPLICATION ACCEPTED BY <br /> F ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION P II/FIIAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION B DATE <br /> n n I t.•7G <br />