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ou <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> FwOFFICE US1 1601 E. Hazelton Ave, , .Stockton, Calif. ` <br /> Telephone: (209)"' 466-6781 <br /> APPLICATION.FOR WELL CONSTRUCTION OR PUMP PERMIT 'Permit-No..� , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ypate. 'Issued ; <br /> (Complete In Triplicate), e <br /> Application is hereby made to the San Joaquin Locel._lioalth D1s,trict for,,a.permit to construct R; ' <br /> and/or install the work herein described. This application ie',made, in cbmpliaaoe, wjtfi San Joaquin <br /> County Ordinance No'. 1862 and the Rules and Regulations of' the San -.Toaquin;todal. Health District. j <br /> JOB ADDRESS/LOCATION 411 Af <br /> CENSUS TRACT, <br /> y <br /> Owner's Name Phone <br /> Address l City <br /> Contractor's Name C! icense ' �Phone <br /> i <br /> TYPE OF WORK (Check), NEW WELL / EPEN /7 RECONDITION /_f DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR /-7PUMP REPLACEMENT <br /> Other L7. <br /> DISTANCE TO NEAREST: SEPTIC _TANK SEWER LINES .,PIT4PRIVY <br /> ;Tr^ <br /> SEWAGE DISPOSAL FIELD Cis SPOOL/SEEPAGE PITP. OTHER <br /> PROPERTY LINE —PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEDUSETYPE OF WELL CONSTRUCTION SPECIFICATIONS _ <br /> Industrial -t,--Cable Tool Dia. of Well Excavation7 77— <br /> ar-Domestic/private . Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation . Gravel .Pack Depth of .Grout Seal <br /> 1 Cathodic Protection Rotary . �1'ype of Grout,, Ac� _ <br /> Disposal. Other `Other'Information ' <br /> Geophysical r Surface Seal Installed BY.: <br /> UMP INSTALLATION: Contractor <br /> Type .of Pump S.P. <br /> 3 <br /> .PUMP REPLACEMENT: <br /> State Work Done ° <br /> — <br /> PUMP I.REPAIR: /_ State Work Done <br /> pES;TRUCTION OF WELL: Well Diameter Approximaie.Depth <br /> Describe Material and Procedure <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 Lbcal 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 ' ALL 'FOR A GROUT INSPECTION <br /> PRIOR TO GE95IW AND A FI INSPECTION. <br /> SIGNED TITLE <br /> } (DRAW PLOT PLAN ON REVERSE SIDE '_. <br /> FOR DEPARTMENT USE ONLY' <br /> PHASE I 4 ' <br /> s APPLICATION ACCEPTED BY' L' A DATE -r7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 3I GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BYy < .DATE: /o/� <br />