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1 <br /> 0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-3d11l) <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner s Name Phone <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 /> Domestic/private Drilled Dia. of Well Casing <br /> .Domestic/public Driven Gauge of Casing 1 z. <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection x . Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Sur£ace"Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> PUMP '.REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: , Well Diameter Approximate Depth <br /> f <br /> Describe Material and Procedure <br /> f 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 /> jafter 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 -c_ - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> `',APPLICATION ACCEPTED BY �) , DATE <br /> ADDITIONAL COMMENTS: / <br /> PHASE II' GROUT INSPECTION PHAS II FI AL IN ION <br /> 1INSPECTION BY DATE INSPECTION BY DATE <br /> 1. h7e nrH <br />