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. 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFLt"'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781;',,, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-.,).91&1 <br /> •. 7�'�33 9/a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application in hereby made to the Sass 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 cam` CENSUS TRACT, <br /> �j w� <br /> r / S_1. ? . <br /> Owne,rts Phone , <br /> . <br /> Address` Y' -, ; `' ' City <br /> Lotr <br /> Contractor's Nam IL License r <br /> TYPE OF WORK (Check): NEW WELL /Z7"*�BEEPEN '/7 RECONDITION /_7 DESTRUCTION,^ J <br /> . PUMP INSTALLATION REPAIR /_7 PUMP REPLACEMENT. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT *-'' OTHER i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �a 1e Tool Dia. of Well Excavation k, <br /> "_Z;;'Domesti.c/private Drilled Dia. of Well Casing 41 ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal .� <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal _. Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> r � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ;REPAIR: / / :State Work Done <br /> s <br /> DESTRUCTION OF WELL: Well Diameter 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 /> 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 to the-best-of- my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 2E2KINR AND A F INSPECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I �/. <br /> APPLICATION ACCEPTED BY DAT ✓ <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />