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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICEtUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> -' A.PPLIIATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Fi <br /> Applicatio (Complete In Triplicate) • <br /> n is hereby made to the San Joaquin Local Health District for a permit to construct tt <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 /> .TOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> ..y ,.. I <br /> Contractor's Name r <br /> Lieerese �I Phonq ' <br /> TYPE OF WORK (Check) : NEW WELL /Z/f EEPEN / / RECONDITION / DESTRUCTION,/77 <br /> PUMP INSTALLATION At-A—ffUMp REPAIR / / PUMP REPLACEMENT-T7 <br /> 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �J SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> PROPERTY LINE - PRIVATE DOMESTIC'�WELL PUBLIC DOMESTIC WELL 0 <br /> INTENDED USE _TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia <br /> D , of Well Excavation /� <br /> omestic/private Drilled Dia, of Well Casing �"� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -t-•---fttary Type of Grout <br /> Disposal f Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_/ S tate,,Wo.rk Done <br /> PUMP -REPAIR: "Staten Work. Done <br /> DESTRUCTION OF WELL: Well Diameter f <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawsland 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 m:Pknowledge and belief. I -WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GRO I AND A"FINAL INSP CT <br /> SIGNED l , <br /> TITLE <br /> DRAW PLOT PIAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY ° <br /> kFPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> .PHASE lI GROUT INSPECTION PHASE II /FINAL INSPECTION � <br /> INSPECTION BY DATE INSPECTION BY ' DATE .1,.7 <br /> 1426 Rev. - I-74 ��� • 077 <br />