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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />•_ F0E -OFFICE UvE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. OS� <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 /> _ n <br /> JOB ADDRESS/LOCATION �G CENSUS TRACT ' ' <br /> Owner's Name <br /> Phone <br /> Address City Q <br /> Contractor's Name , License #01_2 e Phone��7• 1 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION _/ / PUMP REPAIR PUMP REPLACEMENT <br /> Other- <br /> DISTANCE <br /> ther DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL `FIELD CESSPOOL/SEEPAGE PIT _ OTHER 4.PROPERTY LINE. <br /> -.- PRIVATE-DOMESTIC--WELT-' -PUBLTC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �•' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public " ; a' Driven Gauge of Casing C, <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By_:_ <br /> PUMP INSTALLATION: Contractor <br /> Typd of Pump H.P. <br /> PUMP REPLACEMENT: / / . State Work Done <br /> PUMP�.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> s;. Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> t 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 est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GXVTING-AND A FINAL TNS ECTION. <br /> SIGNED TITLE -- <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE' <br /> ADDITIONAL COMMENTS: <br /> PHASE II T N E ION PHASE IWIFINAlf I SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> V u l L 9G n,__ 1 -]A <br />