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SAN JOAQUIN LOCAL HEALTH DISTRICT EFO�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ),o <br /> THIS PERMIT EXPIRES l 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 Ssn 'Joaquin! <br /> County 'Ordi.nance Na. 1862 end the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .� r Lt/ , CENSUS TRACT <br /> Owner's Name {� > Phone <br /> pr <br /> Address �f Gln City . . C'so?D� I <br /> Contractor's Name ,� License # 12,3 Phone <br /> TYPE OF WORK (Check) : NEW WELL/� DEEPEN / f + RECONDTTTON /" DESTRUCTION / 7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/_7 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 T-, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otect_ion 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 /> PUMP REPLACEMENT.: ,L / / State Work Done <br /> PUMP .REPAIR:. / / State Work Done <br /> DES•TR_UCTI.O_N OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> /(DAAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIOW ACCEPTED BY wl DATE ' �� a �" <br /> ADDITIONAL COMMENTS: ; <br /> PHASE It G ! ON PHASE INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br />