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v SAN UIN LOCAL€]CAL <br /> FOR:OFFICE USE: 4 HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. � <br /> i 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 four a permit to construct <br /> and/or install the work herein: described. is application is made inlicompliance with San Joaquin. <br /> County Ordinance No. 18 aJ the Rules d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name / <br /> Phone <br /> Addressof <br /> Contractor's Names <br /> License <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/_' RECONDITION /_7 DESTRUCTION /7 ; <br /> PUMP INSTALLATION -/—/ PUMP REPAIR /77 PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMEST <br /> INTENDED USE IC WELL ' PUBLIC` DOMESTIC WELL <br /> YPv <br /> TE OF WALL CONSTRUCTION SPECIFICATIONS \, 1 <br /> Industrial � Cable Tool Dia. of Well Excavation <br /> � V ! <br /> Domestic/private Drilled Dia, of Well Casing <br /> _ Domestic/public Driven <br /> .�� Gauge of Casing y <br /> Irrigation Gravel Pack- Depth of Grout Seal ;' l <br />- Cathodic Protection Rotary Type of Grout �I <br /> Disposal Other. Other Information <br /> Geophysical Surface Seal Installed B <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , i� <br /> SCate Work Done i <br /> PUMP -REPAIR: <br /> State Work Don <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <br /> and the State of California pertaining to or regulating well "construction. ' Within FIFTEEN DAYS <br /> WELL DRILLERS REPORT of the well and notify them before putting the..wel <br /> after completion of my work' on a new well, I will'furni.sh the San Joaquin Local Health District a i <br /> ]. in.use... The above <br /> information is true to the-best of my.-knowledge and belief. I WILL CALLi; FOR A GROUT INSPECTION Vim' <br /> PRIOR TO GROU ING AND A I'INAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> kPP CATION ACCEPTED BY <br /> kDDITIONAL COMMENTS:' DATE27 <br /> PHASE 11 GROUT INSPECTION P SE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY ;i DATE <br />''4)E H 1426 <br />