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r - "N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOE•rOFFICE USE: 1601 E. Hazelton Ave..,' Stockton, Calif. <br /> Telephone: (209) 466-6781 ti <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o2-3, • <br /> (Complete In Triplicate) 11 <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 �,- -P1_ CENSUS TRACT <br /> 01 <br /> Owner's Namey� � y� Phone <br /> J <br /> Address 3 7 - a d City <br /> i <br /> Contractor's Name License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/� DEEPEN '/� RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / 7PUMP REPLACEME <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 <br /> Irrigation Gravel Pack Depth of Grout Seal � . <br /> Cathodic Pr-otection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface' Seal Installed By: <br /> PUMP INSTALLATION: Contractor : <br /> Type of Pump H.P. Q <br /> PUMP REPLACEMENT: f% State Work Done <br /> PUMP :REPAIR: /_ State Work Done - <br /> E&TRUCTION OF WELL: Well Diameter pximate 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, I will furnish the San Joaquin Local Health District :a <br /> WELL DRILLERS RE ORT 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 FORA GROUT INSPECTION , <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ,. FOR .DEPARTMENT USFZNLY <br /> PHASE <br /> APPLICATION 1ACCEP;Ifib <br /> BY <br /> ADDITI NAL COMMENTS: <br /> �PHASE .II GROUT ;'INSPECTION PHASE II FINAL INSPECTION <br /> �NSPZCTIONBY Y1ATE INSPECTION BY DATE l i <br /> hE A,1.4.26� . Rev. 1-7.4 . , , w 1-74 2M �+ <br />