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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: " 1601 E. Hazelton Ave. , ,Stockton, Calif. '!� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No.77. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f Date Issued / <br /> (Complete In Triplicate) <br /> Application is hereby 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 /> JOB ADDRESS/L ON CENSUS TRACT M <br /> Owner's Na Phone <br /> Address ` o" Cit . r <br /> Contractor's Name License #169"37E�Plione ���t��`r <br /> TYPE OF WORK (Check) : NEW WELL/�/ DEEPEN / / RECONDITION /� DESTRUCTION I�T <br /> PUMP INSTALLATION / / PUMP REPAIR /'X—PUMP REPLACEMENT 1_7 <br /> Other <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 WELL <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 <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: / / State Work Done � <br /> PIMP .REPAIR: / State Work Donk"/�'"-`- <br /> DES-TRUCTION OF WELL: Well Diameter Approximate 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 Local Health District' s <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in uge. 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 AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> -- FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />