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AQGIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE' USE: 1601. Hazelton Ave. , ,Stockton, Caln. <br /> ,r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L//7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED — Date Issued �g <br /> (Complete In Triplicate) <br /> Application is Greby 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 D.istrt;t. " <br /> JOB ADDRESS/LOCATIONG CENSUS TRACT <br /> Owner's Name cc CC�LC'� Phone <br /> Address .. (} -`'!•. City <br /> Contractor's NameLicense # 'Cd fries Phone <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN17 7 RECONDITION -7DESTRUCTION /� . <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 - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC. WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation O <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 /> Disposal Other Other,-Information <br /> Geophysical Stirface:Seal Installed_ By ,__� <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump H.P.. . . . ` u[ <br /> PUMP REPLACEMENT: / / . State Work Done <br /> PUMP -.REPAIR: / State Work Done <br /> DES-iRUCTION OF WELL: 7Well 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 istzict <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 Distxict a . <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well .in use The above <br /> information 's ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A'FINAL INSPECTION. <br /> SIGNED` TITLE <br /> (DRAW PLOT PLAN--ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Td�/ <br /> APPLICATION ACCEPTED BY. <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE . ' <br /> p� <br />