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i! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP.,;-OFFICE USE:----. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I� <br /> /APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' 6- Sla <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issuede�7� <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. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION �- f CENSUS TRACT <br /> Owner's Name ~� <br /> � Phone ' <br /> Address City . <br /> Contractor's Name License # Phone <br /> it I <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN '/_7 RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION /,W PUMP REPAIR/ _PUMP'REPLACEMENTI-7 <br /> f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,-PITFPRIVY <br /> I. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPEATY"LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> b INTENDED. USE TYPE-OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool— Dia. of Well Excavation <br /> it Domestic/private '� Drilled Y Dia. of Well Casing <br /> :1I Domestic/public Driven Gauge_ of Casing. <br /> 1l Irrigation Gravel Pack:7— Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout i <br /> �j Disposal Other Other Information I <br /> I!. Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Puap7 H.P. , <br /> PUMP REPLACEMENT / / Stare Work.Done <br /> PUMPE ' <br /> 'REPAIR: / State Work "one <br /> it <br /> DESTRUCTION OF WELL: Well Diameter {' Approximate Depth j <br /> Describe Material and Procedure <br /> I,.hereby agree to comply with all laws an4k,-regulations of the San Joaquin Local Health District ; <br /> aiidll-the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS f <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 /> PRIaR TO GROiTT G AND F AL INS CTION. ; <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i <br /> I� y FORDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATE2 <br />