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7ol <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE SE: 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 �` s <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. i <br /> JOB ADDRESS/LOCATION , F CENSUS TRACT r <br /> I <br /> Owner's Name Phone <br /> AddressCity ' <br /> LicensebContractor's Name <br /> -- - _j <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / /. DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 � r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE IT OTHER <br /> PROPERTY LINE - PRI ATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS.. <br /> Industrial lejool Dia, of Well Excavation47 <br /> �b <br /> Domestic/private Drilled Dia, of Well Casing /(42 <br /> D stic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal i---- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other. Other Information <br /> Geophysical Surface Seal Installed By: r' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r' H.P. <br /> PUMP REPLACEMENT:: / / State Work Done , . <br /> PUMP �.REPAIR: State Work Done ` <br /> E <br /> DESTRUCTION OF WELL: Well Diameter - - - —Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with. allml ' s and regulations of the. "San Joaquin Local "Health District <br /> and the State of California 'pertaining to or regulating well '"coiRstruction. ' 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 tr to the bestknowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN A FI AL I TIO <br /> SIGNED TITLE <br /> DRAW PLOI PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ITT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ' 1177. _ 2 a <br />