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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.:OFFICE USE: V1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ����7777 r� <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. � <br /> II <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �I (Complete In Triplicate) <br /> f Application is hereby made to the San Joaquin Local Health District for a permit to Construct <br /> f and/or install the workl'`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 /> 4 r <br /> JOE ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name jj Phone <br /> Address II. City , <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN /�� RECUNDITiON �1-7�DESTRUCTION <br /> PUM& INSTALLATION ./ / PUMP REPAIR -/? PUMP l7EPLACE�T /7 <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 I�! TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public ��Driven Gauge of Casing <br /> Irrigation iIl Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout..»: <br /> DisposalI Other Other Information <br /> Geophysical II Surface Seal Installed B <br /> �i. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /�./ State Work Done -� <br /> PUMP �REPAIR: /! / State Work Done <br /> SES:TRUCTION OF WELL: We11.Diameter Approximate Depth <br /> Desc�ibe to ial an-a Procedure <br /> I hereby agree to comply,iwith all laws affd regulations 6f the San Joaquin Local Health D strict <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 <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 CAL A GROUT INSPECTION <br /> PRIOR TQ GROUTING AND A VINAL IN PECTION. <br /> SIGNED t' \ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPAaTMENT USE ONLY <br /> PHASE I , F <br />`APPLICAT ON ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br />. PHASE II GROUT INSPECTION P ffFINAL INSP ON, <br /> INSPECTION BY i . DATE INSPECTION BY TE <br /> E`H_1.426 R :11,1, r h/75 2M <br /> Rev. I-74 <br />