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SAN JOAQUIN LOCAs, HEALTH DISTRICT <br /> FQF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r� Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -5 <br /> C� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1 � <br /> Application is her11 (Complete In Triplicate) <br /> eby 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 ain'd the` Rules and Regulations of the San Joaquin Lo <br /> {I cal Health District. <br /> JOB ADDRESS/LOCATION /;7SD OC�ej [� <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> tt Address <br /> f City.(. ;Oj az <br /> Contractor`s Name `- <br /> License �f� a f�� Phone <br /> TYPE-0-F- WORKti.(.Ghack) ; NEW-WELL --DEEP EN <br /> _/�/—REGOND ITION /`/.. DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT <br /> Other,/ / <br /> DISTANCE TO NEAREST: SEPTIC,.�TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT <br /> OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ES <br /> PUBLIC DOMTIC WELL i <br /> INTENDED USE TAPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private TI Drilled Dia. of Well Casing <br /> Domestic/public i� Driven <br /> Irrigation 7—iGauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _51— Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contracto r <br /> Type of Pump H.P. -� <br /> PUMP REPLACEMENT: State Work Don � -- D <br /> PUMP .REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 HAYS <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 /> PRIOR TO <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPE <br /> OUTING CTION <br /> A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE-SIDE) ° <br /> PHASE I FOR DEPARTMENT USE ONLY G' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE /0— <br /> PHASE II GRDUT IN$P CTIQN PHAS II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY } <br /> DATE 8 <br /> r^� f <br /> T_.E-H 1426_. Rev. . l j�7 LT .__. M <br />