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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TF70E-"GVFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 5 <� ?/'s <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION . �� b .� CENSUS TRACT <br /> Owner's Name Y''2 ` Phone <br /> Address a -e City ' 5 DCI ' <br /> Contractor's Name--S,,r_/ License # Phone <br /> TYPE OF WORK (Check):- NEW WELL/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION . <br /> -PUMP`INSTALLATION / / PUMP REPAIR / / PUMP REPLACENM J <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 V&LL - PUBLIC DOMESTIC WELL ■� ' <br /> INTENDED USE TYPE OF WELL %- CONSTRUCTIONSPECIFICATIONS <br /> Industrial Cable Tool Dia. of -Well Excavation-- <br /> Domestic/private <br /> xcavation-Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �. <br /> Irrigation - Gravel Pack r 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 `1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / - -State Work Done <br /> PUMP REPAIR: / / State- Work Done <br /> L( <br /> ?ESjRUCTION OF WELL: Well Diameter Ap roximate Depth Ul" <br /> — De cribe 2M2terial and Procedure 6 <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 , <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 /> 'RIOR TOG OUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D PARTMENT USE ONLY <br /> PHASESI - , <br /> APPLICATION ACCEPT r DATE "23 4 <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE FTNa INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -�� `- <br /> . . <br /> . �0:TT ,,.,e <br />