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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 Issued5/, 7� <br /> J. (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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATIONr } <br /> -• CENSUS TRACT <br /> � r . <br /> Owner's Name phone <br /> Address �� c City <br /> Contractor's Name LicensePhon� <br /> / Y <br /> ArV <br /> TYPE OF WORK (Check) : NEWjWELL DEEPEN / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> ` <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /,*(> CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTX LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE .TAPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . fi.. Cable Tool. Dia, of Well Excavation <br /> Domestic rt <br /> /private '�:Drilled Dia. of Well Casing <br /> Domestic/public ;1 Driven Gauge of Casing <br /> Irrigation 't Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection '. i <br /> Rotary Type of Grout e <br /> B,'isposal~ Other Other Inform i <br /> Geophysical Surface Seal sta led B : <br /> PUMP INSTALLATION: Contra t'or` <br /> - Type o,f Pump 14.P. [} <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> r r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Dscribe'Material and Procedure <br /> I hereby agree to c mply 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 G OUTIN A' INALINSPECTION. <br /> SIGNED TITLE <br /> �. (DRAW PLOT PLAN ON REVERSE SIVE) <br /> } <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSVECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H`14.26 Rev. , 1-74 . - b/17 _ 2M <br />