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l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 t. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ;� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� <br /> 1 THIS PERMIT EXPIRES 1 YEARw'FROM DATE ISSUED Date IssuedS <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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San •Joaquin Local Health District.. <br /> JOB ADDRESS/LO TION CENSUS .TRACT ' <br /> Owner's Name Phone <br /> O <br /> 4 Address ll .k� +�- V VIZZ4e City <br /> 4 <br /> Contractor's Name &4"J <br /> License <br /> F <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / I DESTRUCTION <br /> PUMPIINSTALLATION / / PUMP REPAIR / / 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 _ <br /> INTENDED USE :TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i— Cable Tool Dia. of Well Excavation _ <br /> )' Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ _ -- <br /> Irrigation Gravel Pack. Depth of Grout Seal x <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical k 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A/ 1_1 " <br /> Type of Pump 4 &./ <br /> PUMP REPLACEMENT: /:c/ State,Work Done 4- <br /> PUMP .REPAIR: / / State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 thelwell and notify them before,putting: the. well in use.. The above <br /> information is true to the best of. m wle(Jge elief. I'•-•WILL CALL, FOR A GROUT INSPECTION <br /> PRIOR TO PROUTIING AND A FINAL 4I N. <br /> SIGNED TITLE — <br /> ( WPMr 7MN ON RlWtRSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED" BY DATE $��l 1 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GR0 NSPECTION PHASE I/F INSPECTIDN <br /> INSPECTION BY DATE INSPECTION BY DATE — <br /> or�%7 2M <br />