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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Noi <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 and1the Rules and Regulations of the San Joaquin Local Health District,. <br /> t <br /> 30B ADDRESS/LOCATION /,/ ��',� ����a�,tnts � CENSUS TRACT . <br /> Owner's'Name I Phone <br /> Address _ z City <br /> Contractor's Name License # . . . . . . Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/7 RECONDITION 17 DESTRUCTION _ <br /> PUMP INSTALLATION / / PUMP REPAIR/-7 PUMP REPLACEMENT %J <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 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation :. t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal _ Other Other Information i <br /> Geophysical Surface. Seal Installed 'By: <br /> i <br /> PUMP INSTALLATION: Contractor • <br /> Type .of Pump A.P. <br /> PUMP REPLACEMENT: .. Ll State Work Done _ <br /> PUMP '.REPAIR: /- State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Ap roximate DepthA* <br /> Describe Material and Procedure 7� <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-bast of-my. knowledge and belief. I WILL CALL 'FOR 'A GROUT INSPECTION <br />` PRIOR TO GR UTING AND A FINAL- INSPECTION. <br /> SIGNED _,7 TITLE <br /> I DRAW PLOT PLAN ON REVERSE SIDE <br />} FOR DEPARTMENT USE-ONLY <br />� PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GROUT INSPECTION PRA,%E IIIJKZN& INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �! 2M <br /> E i 1426 Rev. i-7!: �t 75 <br />