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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -To—r,-'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 S' , S CENSUS TRACT <br /> Owner's Name P/ N1 # ,:)& <br /> ¢'Y�o <br /> Address S J4 City <br /> License 4QI0 Phone ,D <br /> Contractor s Name , M �- N � <br /> TYPE OF WORK -(Check-Y--. `NEW-WELL / I DEEPEN / / RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: .- SEPTIC TANK SEWER LINES PIT PRIVY �. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE` PIT OTHER <br /> PROPERTY LINE 4—AIVATE,DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPEeOF WELL - � CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool `Dia. of Well ExddVa-t on �- <br /> `'Dome`stic/private Drilled Dia. of; Well Casing <br /> Domestic/public Driven Gauge of Casing - <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary �� Type of Grout [, <br /> Disposal Other Other Information <br /> Geophysical , " ` Surface Seal Installed By : c <br /> PUMP INSTALLATION: Contractor IV <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / Sta. -6 Work Done <br /> PUMP .REPAIR: / / State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of the Sari 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 ;6 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ,A�D A INAL INSPECTION. <br /> SIGNED TITLE•: . <br /> (DRAW PLOT PLAN DN REVERSE SIDE <br /> ' F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ►Z <br /> ADDITIONAL COMMENTS. PHASE III_rr/FINAL INSPECTI0,N <br /> r PHASE II GROUT INSPECTION <br /> INSPECTION BY 'FoDATE INSPECTION BY DATE t:7 <br /> t, 0/77 _ 2M <br />