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SAN JOAQUfN LOCAL HEALTHDfSTRiCT <br /> FOE OFFICE USE: 1601 E. Hazelton' Ave. , -Stockton,"Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES: 1 YEAR FROM.-DATE -ISSUED Date Issued <br /> (Complete- In Triplicate) <br /> Application is hereby made ta� the San Joaquin Local health District for a permit to construct <br /> and/or install the.work,herein described. This application is made incompliance With San Joaquin' <br /> County Ordinance No,.. l$62,and"the Rules d Regulations,of�:.Ltan Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION wt �. _ CENSUS TRACT — <br /> r <br /> Owner's Name Phone <br /> City <br /> Address ' <br /> License # Phone <br /> Contractor's Name. �,W" �- <br /> TYPE"OF WORK (Check): NEW WELL /7 DEEPEN RECONDITION <br /> / DESTRUCTION r <br /> s PUMP INSTALLATION / UMP REPAIR /� PUMP REFI,ACEMENT I T <br /> _ Otheir./ <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY i <br /> i SEWAG91DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL `S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION .SPECIFICATIONS O <br /> Industrial`*�if �_ Cable Tool Dia. of Well Excavation <br /> =Domestic/private ,i Drilled Dia, of Well CasingI <br /> Domestic/public•----- Driven Gauge of Casing.' <br /> Irriga'r3oia:_j; ,) s_ <br /> i Gravel Pack Depth of Grout"Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal : ` Other Other Information <br /> -•~� Surface Seal Installed B C <br /> Geophysical t . <br /> PUMP INSTALLATION: Contractor { <br /> Type ,of Pump <br /> . ,. State Work Dome-�-�'Ul-L ;_ <br /> PUI�' REPLACEMENT• / / � <br /> 4-:` - - - <br /> PUMP :REPAIR: / State Work Donees 4 -- <br /> - $E� L4 <br /> �, - -:..:,=ter.=• — <br /> � pproximate Depth „ <br /> � ES•TRUCTION OF WELL: Well Diameter .. - A0 <br /> proximate <br /> 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 Californialpertaining to-or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work: on a new well, I will €urnish..the; <br />