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-` .. = : SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (. 209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�THIS PERMIT EXPIRES YEAR FROM DATE ISSUED Date Issued l —� <br /> (CompletelIn 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 Jo4quin <br /> County Ordinance No. 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION ` CENSUS TRACT <br /> Owner's Name g Phone <br /> j ! <br /> Address Cit <br /> C� �� "� �' -- -- - - <br /> Contractor's Name <br /> i License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br />'; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE 'DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL + CONSTRUCTION SPECIFICATIONS <br /> j Industrial Cable Tool` Dia, of Well Excavation (,l� <br /> i-*'� Domestic/private F Drilled i Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing t <br /> Irrigation I Gravel Pack Depth of Grout Seal - _ Y <br /> Cathodic Protection Rotary. Type of Grout <br /> Disposal I Other t Other Information ? -- <br />} Geophysical Surface Seal Installed <br /> iPUMP INSTALLATION: Contractor <br /> F Type of Pump fey' jHa.P. <br /> 1 PUMP REPLACEMENT: / / State Work <br /> �PUMP �.REPAIR: / / State Work Done <br /> IDES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material andProcedure <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 we11 ''construction. Within FIFTEEN DAYS <br /> r,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 notify4them before putting the well in use.. The,,above <br /> linformation is true to the best of" myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND 'A FINAL INSPE ION <br /> SIGNED .j TITLE <br /> (DRAW ELUT PLAN ON REVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> kPHASE I f <br /> DATE 27--7 <br /> :APPLICATION ACCEPTED BY <br /> 'ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE d _77 <br /> i 1177 _ 2M <br /> 17 14 1G7ti Rotir_ 1-7LL - -- <br />