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M SAAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> le <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT Permit No. -/G�3 <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED --1 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin LocalHealth <br /> District for made in co per it to construcoaquin <br /> ct <br /> and/or install the work herein described, This application <br /> County Ordinance No. 1$62 and the Rules and Regulations of the <br /> San <br /> Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION ` <br /> Phone <br /> Owner's Na+ <br /> / 7 Cityor <br /> l4�f <br /> Address <br /> Contractor's Name License #��Phone <br /> u <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION I / DEREFLACEMENTION �I� <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP <br /> 0 ther J-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ EPAGE PTT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Dia, of Well Excavation <br /> Industrial Cable Tool <br /> Drilled Dia. of Well Casing <br /> - Domestic/private Driven Gauge of Casing , 2— <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal rd <br /> Rotary Type of Grout <br /> Cathodic Protection -- y Other information <br /> Disposal Other <br /> Surface Seal Installe <br /> Geophysical <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump u <br /> PUMP REPLACEMENT: / / State Work. Done <br /> PUMP REPAIR: / / State Work Done <br /> llApproximate Depth <br /> ` DES•TRUCTION OF WELL: Well Diameter (A - <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I and the State of California pertaining to or regulating Snell 'construction. Within FIFTEEN DAYS <br /> after completion of ork on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REP T of 'the well and notify them before putting the .well in use. The above <br /> information is rue to the of. -knowledge and belief, I WILL CALL FOR A GROUT INSPE ION <br /> PRIOR TO GR FINAL NS ION <br /> SIGNED TITLE <br /> DRAW PUT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p I/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE .100 1 <br /> INSPECTION BY DATE <br /> � � , <br />