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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFI E USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7� <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/LOCATION CENSUS TRACT <br /> Owner's Name Phone . <br /> Address City <br /> Contractor's Name Licensees Phone <br /> y <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN '/? RECONDITION �_ DESTRUCTION /7 <br /> PUMP INSTALLATIGN / / PUME' REPAIR-/� PUMP REPLACEMENT J� � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY qr ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 'O <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL' PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia,. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �_ A.P. <br /> PUMP REPLACEMENT: . State Work Done - r <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 the well and notify them before putting.. the..well in.use.... The above <br /> information is true to the•best,of- my ,knowledge and belief. I WILL CALL -FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INS ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTIJENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �T' T <br />