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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ','OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 b <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued1 7q <br /> (Complete In Triplicate) <br /> Application is hiereby'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 />':TOB ADDRESS/LOCATION CENSUS TRACT _ <br /> 1 Phone <br /> Owner s Name <br /> f <br /> Address ] i City <br /> Contractor's Name <br /> _-^ License_, �� . .Phone <br /> TYPE OF WORK (Check) : NEW WELL I r -DEEPEN I RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION &�,TUMPIREPAIR / / PUMP REPLACEMENT IIT i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT J OTHER r <br /> PROPERTY ILINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL L�} <br /> INTENDED USE TYPE OF�.WELL CONSTRUCTION SPECIFICATIONS <br /> industrial. f Cable Tool Dia. of Well Excavation <br /> s/ <br /> :., Dia. of Well' Casing <br /> - C Domestic/Private �_ Drilled - --, �--- <br />�., _ Domestic/public - Driven Gauge of Casing`"' <br /> Irrigation -�' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection' '' Rotary Type of Grout <br /> Disposal Other Other Information 6;� <br /> Geophysical .-'I Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ' <br /> Type,of Pump H.P. - <br /> PUMP REPLACEMENT: ` State Work Done. __L. <br /> PUMP .REPAIR: /TI <br /> State Work Done <br /> DESTRUCTION OF WELL: Well :Diameter'll Approximate Depth _ <br /> Describe Material and,P-rocedure <br /> } <br /> I hereby agree to comply with all laws and regulations of the Sa1-i. Joaquin Local Health District <br /> and the of Califbrnia pertaining �o or'regulating well 'construction. Within FIFTEEN DATS <br /> after completion of my work on a new well., Ijwili 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 ,t est._.a.f_m. knowled.ge.:and-belief.--I-WILL-CALL FOR A GROUT INSPECTION <br /> ( PRIOR T G NGSPECTION. <br /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ` FOR DEPART NT USE ONLY q <br /> PHASE I J DATE I I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: i P I /F NAL INSPECTIO <br /> PHASE II GROUT INSPECTI N DATE Z <br /> i INSPECTION BY I TATE INSPECTION BY <br /> 1177 <br />