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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perm <br /> rt No. / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued <br /> - (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to construct <br /> described. This application is made in compliance with San Joaquin: <br /> and/or install the work herein <br /> County Ordinance No. 1862 and1the R les and Regulations of the San 'Joa uiri Local, Heil District- <br /> CATION <br /> CE�NSU <br /> JOB ADDRESS/LOS TRA A <br /> Phone <br /> Owner's Name <br /> Address + City <br /> Contractor's Name �� License #P0&4 <br /> Phone <br /> a <br /> TYPE OF WORK -(Check) :--.•NEW WELL / I-DEEPEN- %/k: RECONDITION F/ DESTRUCTION /^T A� . <br /> PUMP INSTALLATION /. / 'UMP':REPAIR /` PUMP REPLACEMENT �• . <br /> ` Other */ / <br /> l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 /> Industr-.al Cable Tool Dia. of Well Excavation <br /> Domestic/private - Drilled Dia. of Well Casing <br /> Domestic/public <br /> "' Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other ` Other Information <br /> Geophysical ' Surf ace Seal Installed By: ... <br /> PUMP INSTALLATION: Contractor�,e <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / /` State Work Done <br /> c <br /> PUMP .REPAIR: / / iState Work Done <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 wel.I construction. Within FIFTEEN DAYS <br /> after compleion of my work on a new well, I will furnish the. San Joaquin Local Health :District a <br /> i 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 GROUTING D FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPART U E ONLY <br /> PHASE I DATE ! <br /> f APPLICATION ACCEPTED BY /(1 <br /> # ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION FHAS � I I FINAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY DATE Z r, (l2- <br /> o/77 - <br />