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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE : SE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209)'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , "!6 <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 Joaquin <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 <br /> Address City <br /> Contractor's Namerl <br /> License #,,77 -H Phone <br /> TYPE OF WORK (Check) : NEW WELL'_ DEEPEN '/ / RECONDITION L7. DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR'/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE <br /> SEWAGE DISPOSAL I'IELD CESSPOOL/SE8 AGE T OTHER <br /> PROPERTY LINE -rPRI ATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I�,Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing4, <br /> D stic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f19 <br /> Cathodic Protection Rotary 'type of Grout <br /> — <br /> Disposal Other. Other Information <br /> Geophysical Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor ./ <br /> — - Type of Pump .' H.P. a <br /> PUMP REPLACEMENT: / / State Work Done '�f �r <br /> PUMP .REPAIR: ,• . J /y State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - - - - �' —Approximate Depth - <br /> Describe Material and Procedure <br /> I hereby agree to comply with, all 'lziws and regulations of the:San Joaquin Local Health 'District <br /> t <br /> and the State of California `peoining to or regulating truction. ' Within FZI'TEEN PAYS <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 tr to the best knowledge and belief. I WILL CAJ4, FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN A FI AL I TIO <br /> SIGNED 1101 TITLE <br /> DRAW PLO PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BYDATE ..3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br />