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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Or, E: <br /> OFFICE US _ 1601 E. Hazelton Ave. , Stockton, Calif. UA` <br /> Telephone: (209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT. EKPIRES 1 YEAR_FROM DATE ISSUED -Date Issued -2 <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 /FC - / CENSUS TRACT <br /> Owner's Name Phone <br /> _ <br /> Address ' 3 11 City -- <br /> Contractor's Name [f <br /> �icse Phone <br />! TYPE OF WORK (Check) : NEW WEWEPEN / / RECONDITION / / DESTRUCTION /7 _ <br /> PUMP I TALLATION /PUMP REPAIR / / PUMP REPLACEMENT / / r ' <br /> Other / / Y, .. T W <br /> DISTANCE TO NEAREST: SEPTIC TANK ,,_SEWER LINES PTT PRIVY <br /> ,0 � <br /> i 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 Well Excavation <br /> . T <br /> t �tsomestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing Ja <br /> Irrigation Gravel Pack Depth of Grout Seal `�Cl <br /> Cathodic Protection A----Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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,VI will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and;notifyrthem before putting thewell in use. . The above <br /> �. information is true to the best of my,dknowl_edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO I AND A FINAL INSPEC <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR :DEPARTMENT USE ONLY <br /> PHASE I � - <br /> APPLICATION ACCEPTED BY DATE �A <br /> ADDITIONAL COMMENTS: ^. <br /> PHASE II GROUT INSPECTION "WAT <br /> SPECTI N <br /> t INSPECTION BY DAT F INSPECT, ONE <br /> l <br /> 0!77 _ 2M <br /> u IA7F '0 , 1-74 - <br />