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SAN JOAQUIN LOCAL HEALTH DISTRICT { ' <br /> kOT�:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. ` ' .10 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT. EXPIRES I 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. 1462 and the Rulp and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION � <br /> CENSUS TRACT F j <br /> Owner's Name f Phone ' <br /> :Z7 S <br /> Address City L&A <br /> Contractor'a Name <br /> _ Li ease # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /"? DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/? PUMP REPLACEMENT 17 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK //0-1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Well /5"" <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial <br /> Cable- Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Z Rotary Type of Grout r.. . <br /> Disposal Other Other Information . <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION Contractor �^ <br /> Type .of Pump .P. <br /> _ <br /> PUMP REPLACEMENT: . <br /> .. / / State WorkDone <br /> F <br /> PUMP .REPAIR: /_ :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter w <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 /> a17dlthe 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 & <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- mi knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO G UTING 'AND A F AL INS CTI <br /> SIGNED I101 <br /> TLE <br /> (DRAW N REV SE SIDE <br /> PHASE i OR DEPARTMENT US ONLY <br /> D <br /> APPLICATION ACCEPTED BY DATE I <br /> ADDITIONAL COMMENTS: <br /> PHAM,I.14ROUT INSPECTIO PHAS III INAL INSPECTI N <br /> INSPECTION BY DATE 42 INSPECTION BY DATE <br /> . •�' l ll7 Da.:. 7....'7 L ...?"'°�1J <br />