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)^r <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4/ <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 Ileaith 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 /> ,SOB ADDRESS/LOCATION � CENSUS TRACT <br /> Owner's Name one <br /> I <br /> Address City . 222.1. <br /> Contractor's Name License # Phone 5ZF YY�c <br /> TYPE OF WORK (Check) : NEW WELL /,7W'DEEPEN '/_7 RECONDITION I7µ DESTRUCTION f-7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/ 7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N11 <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 <br /> Domestic/private Drilled Dia. of Well Casing "ald614_) <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 Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> k PUMP REPLACEMENT: / J State Work Done <br /> PUMP ,.REPAIR: Y:. / _V State Work Done.- -. - _ -=-- _ r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <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 well construction. Within FIFTEEN DAYS <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 /> PRIOR TO GR TING 'AND A MAL INSP-MIONo <br /> SIGNED a TITLE 1 <br /> (DRAW T PLAN ON REVERSE §IDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 26,. <br /> , ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIA". INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br />