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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone: (209) 466-6781 A <br /> � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7���� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby <br /> to the San Joaquin Local Health District for a permit to construct kk <br /> and/or install the work herein described. This application .is made in compliance with San Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION / . CENSUS TRACT <br /> Owner's Name Phone e3 ) <br /> Address <br /> City - -7 ' <br /> Contractor's Name Q�C/,l _ ,License # - Phone 30'? <br /> TYPE OF WORK (Check) : ~ NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> 4W _ i/� — - <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / - <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT 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 /> 4 Industrial Cable Tool Dia. of Well Excavation <br /> j Domestic/private Drilled Dia, of Well Casing _ <br /> _ _ ___D,omestic:/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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump — H.P. <br /> t <br /> PUMP REPLACEMENT:'' State Work Done S' � r fes' <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 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 GROUPING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH&SAOI I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE l Z 7 7 <br /> 2M <br /> L+ v 7 /.rfL n___ 1 7/. . -•may <br />