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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: P 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�7 <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,..�4 <br /> JOB ADDRESS/LOCATION / /�f ®�� - CENSUS TRACT ; <br /> Owner's Name Phone <br /> Address city <br /> � z <br /> Contractor's Name , y� � /� C l�� _ License # Phone <br /> I <br /> r . <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN ./_/ RECONDITION /_/ DESTRUCTION /- ff <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT i <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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing d <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: Contractor <br /> Type of Pump � -'�_ H.;P.--- <br /> PUMP REPLACEMENT: S;tate Wo k Done a <br /> PUMP REPAIR: / / State Work Done tea•-- f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure # <br /> i <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 GKOLTT .INSPECTION <br /> PRIOR TO GR TING AND A F NAL 4NSPECTION. <br /> SIGNED TITLE 26� <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 INSPtCTION PHAS III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - BATE <br /> ri <br /> 2M <br /> �� , <br /> 6, 77 _ <br />