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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Foy,,'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 &--Ao-JZ <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 /tJ CENSUS TRACT <br /> Owner's Name l G Phone <br /> Address A City S CAZO A2 <br /> Contractor's Name License #��Phone - <br />.TYPE OF WORK (Check),. NEW WELL L_7 DEEPEN '/7 RECONDITION /7 DESTRUCTION.,f�Y. ' <br /> PUMP INSTALLATION � PUMP REPAIR '/� PUMP PLACEMENT <br /> Other / / — <br />`DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE RQMESTIC WELL' '_ _PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.7of Well Excavation <br /> Domestic/private Drilled Dia...of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal {1� <br /> Cathodic Protection Rotary Type of Grout I <br /> Disposal Other Other Information <br /> Geophysical SAY. Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor � <br /> Type .of Pump H.P. 1 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP I,REPAIR: \ /7 :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 /> ELL 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 FO A GROUT INSPECTION <br /> PRIOR TO G UTJNG -MD A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW 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- INSPECTION PHASVIIZMINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE <br />