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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW OFFICE USE: 1601 E. Hazeltoh Ave. , Stockton, Calif. <br /> Telephone: (209) 466»6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Hereby made to the Sun 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 ^IJs CENSUS TRACT <br /> Owner's Name Phone 24 <br /> Address iva, City ' a F <br /> Contractor's Name <br /> c �- � License Oa 0 2. Phone Z-57:5 J 7 � <br /> TYPE OF WORK (Check): NEW WELL A DEEPEN /_7 RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/7 PUMP REPLACEMENT 17 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool . Dia. of Well7Excavation 5'1-'T:-__7-1_ '- - ; <br /> Domestic/private Drilled Dia. of Well Casing Y'�4 s/gsr <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack -'Depth of Grout Se-al: - <br /> - Cathodic <br /> eal- "Cathodic Protection Rotary' Type of Grout <br /> Disposal Other Other Information ' ' <br /> Geophysical <br /> Surface-Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,RES-TRUCTION OF WELL:' Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 17TWAX INSPECTION. <br /> SIGNED' �- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PBA5 IzIjFZNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /~� <br />