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V1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt�rOI'FICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> I� 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. 186,2 and the Rules and Regulations of the San -Joaquin Local Health District: <br /> JOB ADDRESS/LOCATIO <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone ' <br /> Address <br /> city , <br /> Contractor's Name icense # PhoneS2_22 " ,/ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/7 RECONDITION <br /> PUMP INS AL /% p DESTRUCTION f_7REPAIR/7 PUMP REPLACEMENT f7Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPO ,gFIELD /'CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLo. <br /> PUBLIC DOMESTIC WELL <br /> INTENDED USE i' TYPE OF WELT, CONSTRUCTION SPECIFICATIONS <br /> ' Industrial �i <br /> I 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, Rotary Type of Grout <br /> DisposalOther Other Information ' <br /> Geophysical Surface Seal Installed — <br /> <i <br /> PUMP INSTALLATION-. Contractor ' <br /> Type of Pump <br /> -H.P. <br /> PUMPREPLACEMENT: • / / State Work Done <br /> PU21.11EPAIR: <br /> /7 State Work Dane { <br /> IES4TRUCTION OF WELL: Well Diameter <br /> Describe Material and ProcedureApproximate Depth ---'-=-� <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well "construction, Within FIFTEEN DAYS <br /> Ifte'r completion of my work on a new well, I will furnish the San .Joaquin Local Health District a <br /> JELL DRILLERS REPORT of the well and ,notify them before putting.. the.-well. in use.... The above. <br />-ntormation is true to th 1tibest ,of my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO O ING AND A F X INSPE ION. <br /> i IGNED -7 1111F <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'HASP, I i <br /> r.PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INS PHASE III INAL INSPECTION f <br /> NSPECTION BY DATE _ INSPECTION BY DATE <br /> E H 1426 1. t <br />