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SAN JOAQUIN LOCAL HEALTH DISTRICT Q <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 y � <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _?-d-:3-Ar" <br /> (Complete In Triplicate) 06.3-tso- 07 i <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/LOCATION 4-� CENSUS TRACT <br /> Owner's Name WPhone <br /> Address 4 t City <br /> F <br /> Contractor's Name License # 7 7 ,Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INST ITION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z00, SEWER LINES PIT PRIVY k , <br /> SEWAGE DISPOSAL FIELD CE 55 POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL z, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> =omestic/private Drilled Dia., of Well Casing <br /> Domestic/public R Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type.,.of Gr.out_.__ y <br /> Disposal Other Other Information ~ <br /> Geophysical Su face Seal--Installed B' : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depths- -_ <br /> Describe Mater-ial 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 the well and notify them before putting the wellin 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 GRO T AND N FINA SP C'PION, <br /> SIGNED TITLE ' <br /> _ (D W_PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT,USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS I I/FINAL INSPECTION �7 <br /> INSPECTION BY f DATE f? INSPECTION BY DATE - ��/ S{ <br />