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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: 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 /�7,6 <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 <br /> CENSUS TRACT � <br /> Owner's Name Phone <br /> Address r z pity <br /> Contractor's Name t License # C :y Phone ' 1 <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /y'�PUMP REPAIR -/77 PUMP REPLACEWNT %f <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 \,S�� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �J <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 By: <br /> PUMP INSTALLATION: ` <br /> Contractor I <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT. / / State Work Done ) <br /> PUMP .REPAIR: /17�State Work Don t <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FI INSPECTION. <br /> SIGNED &4 TITL <br /> (DRAW PLOT PLAN ON REVERSE SI E <br /> ?a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE ' ! 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PAA I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDAIS - /- <br /> E H 1426 uo„ 3_7A <br />