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Y&y'.. <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 72 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> "SUS TRACT <br /> Owner's Name Phone. , <br /> { <br /> Address � city , /I, - � � <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL .DEEPEN '/ RECONDITION 1-7 DESTRUCTION / 4 <br /> PUMP INSTALLATION / / PUMP REPAIR /77 PUMP REPLACEMENT <br /> tk Other <br /> DISTANCE TO` NEAREST: SEPTIC-'TANK SEWER' •LINES PIT PRIVX <br /> - —'x SEWP;GE DISPOSAL_YKELD„ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL , PUBLfiC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION -SPECIFICATIONS' R <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ <br /> Domestic/private Drilled - �' Dia.�of Well. V <br /> Domestic/publid 'Driven Gauge of Casing ,� <br /> Irrigation Gravel Pack' Depth,of Grout;Seal :. - - - - <br /> Cathodic Protection Rotary Type of Grout' ` <br /> r. Disposal ` ,Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION.- Contractor}" <br /> Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP 'REPAIR: <br />_ j/1_ _-State Work Done <br /> f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth d�r <br /> -- Describe Material. and Procedure f <br /> 1 <br /> I hereby agree to comply with all laws and-regulations of the San oaquin--Local Health District <br /> And the State of California pertaining to or regulating well."constructions. 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 FINAL INSPECTION. f <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: : r0 e P o { <br /> PHOUT INSPECT I PRASYy INAL INSPECTIONi <br /> INSPECTION,.BY•' DATE p7r INSPECTION BY DATE . <br /> E H 142A4 r '.,.7�7l. ti' � �(� i. /-7e nor <br />