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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. l <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 j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 162 and- the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (JL vt o r✓ W-S CENSUS TRACT <br /> Owner's Name 0, Phone - o 7 <br /> Address cityN <br /> Contractor's Name �� �yy J -�f' ]Oals License Phone a <br /> cJ <br /> TYPE OF WORK (Check): NEW WELL -/7 DEEPEN -/7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR PUMP REPLACEMENT /7 1 ' <br /> Other 1-7 <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 WELLf <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 <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 Y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> To yr>1 <br /> DESTRUCTION OF WELL: Well Diameter Approa�imate Depth <br /> Describe Material and Procedure <br /> f <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 i <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 D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> ;- DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICAT-ION'"•ACCEPTED BY, - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II . OUT.•INSPECTION PHASE ILL FI AL INSPECTIO <br /> INSPECTION.,BY,­ ` "F '; 4,=DATE INSPECTION B j DATE <br /> R ii 71.7 n--- � yip• .. +�!/ had nwe <br />