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' JOAQUIN LOCAL .HEALTH DISTRICT ' <br /> F'OR':OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cal . <br /> Telephone: (209) 466-6781 <br /> APPLICATION­FOR -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 Joaqu: <br /> County Ordinance No. 1862 and the <br /> ' les and Regulations of the San Joaquin Local Health Di§trict <br /> JOB ADDRESS/LOCATION �1 D r oUcl CENSUS TRACT ' <br /> Phone - <br /> Owner s Name E�.•: <br /> City <br /> Address _ <br /> Contractor's Name License Phone <br /> 4� ' r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN IRECONDITION l_T DESTRUCTION /7 <br /> PUMP INSTALLATION _0 PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKl�� SEWER LINES PIT PRIVY L <br /> SEWAGE DISPOS , 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 <br /> _XDomestic/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 Surf <br /> a <br /> ce Seal Installed BY: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump i f r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State 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 Distric <br /> and the State of California pertaining to or regulating well'-construction. Within•FIFTEEN DAT: <br /> after completion of my work n a new well, I will furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT o e well and notify them <br /> andfbelief.ore I the well in use..WILL CALL FOR A ZROUTeINSPECTI01 <br /> information is tru o the best of my knowledaboveg <br /> PRIOR TO .GROU INS E ON, <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> o <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ;.DATE -g�1$ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE AI/FINAL INSPECTION <br /> PHASE II GROUT -INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> _ —�. _ .V, - 1177. _ 2M <br />