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SAN JOAQUIN LOCAL HEALTH DISTRICT 1l' <br /> FOFi'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 Issue^ <br /> 11 (Complete In Triplicate) <br /> Application is hereby made totithe San Joaquin Local, Health District for a permit to construct <br /> and/or .install the work herei'h described. This application is made in compliance with San Joaquin: <br /> County Ordinance No. 1862 and'IIthe R�alee and Regulations of the 3a Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION17 1 CENSUS TRACT <br /> Owner's Name Phonee <br /> Address City <br /> Contractor's Name License �?> � hone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /? RECONDITION /J DESTRUCTION /f <br /> PUMP INSTALLATION/ / PUMP REPAIR '/-7 PUMP REPLACEMENT <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY fi <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 ] <br /> Industrial t Cable Tool Dia. of Well Excavation 1 <br /> VDomestic/private 1 Drilled Dia. of Well. Casing <br /> Domestic/public ! Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: . . . <br /> PUMP INSTALLATION: Contractor { <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP :REPAIR: / / S'6a6e Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <br /> Describe Material and Procedure . . . . . <br /> I hereby agree to comply withiall 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 ROUTING AND F AL INSPECTION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE Sl <br /> 01 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Vpv_ 1-76 i` ` h/75 2M <br />