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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS' PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> i..� (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/LOCATION - CENSUS TRACT <br /> Owner's Name Phone <br /> City _ a <br /> Address <br /> -7, <br /> Phone <br /> Contractor's Name I <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/ / ; DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES,-- ­­ PIT PRIVY <br /> SEWAGE AIg -- SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED,--USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �. ." <br /> Industrial- I Cable Tool Dia, of Well Excavation <br /> �Do�estic/pr.ivate Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> �. Gravel Pack Depth of Grout Seal <br /> Type of Grout <br /> Cathodic Prot6c•tiona R6tary <br /> Disposal 4 YP , <br /> :: rC'� r-Other Other Information <br /> �-� _ <br /> Geophysical - � Surface Seal Installed B <br /> PUMP INSTALLATION:, Contractor `<- <br /> { Type of Pumper <br /> PUMP REPLACEMENT: .' / / State'�Work Done s .. <br /> PUMP .REPAIR: - / / State Work Done <br /> fr <br /> Approximate Depth ' <br /> ( DESTRUCTION OF WELL: Well Diameter <br /> F Describe Material and Procedure <br /> J <br /> i. <br /> jI hereby agree to comply with all laws and regulations cal Health District , <br /> of the San Joaquin Lo <br /> Within FIFTEEN DAYS <br /> and the State of California pertaining to or regulating well"construction. <br /> Fafter 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 put:ing­the..well_.in use. __The. above- _x <br /> jinformation is true to the bests.of--my=knowledge aiid-Vb ief. I WILL CALL FOR A GROUT INSPECTION <br /> `PRIOR TO GROUTING' ANDA FINAL PECTION. „ ;,fin <br /> TITLE r { <br /> SIGNED <br /> M {DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE If DATE 449-1 <br /> iAPPLICATION ACCEPTED BY i y �M <br /> ADDITIONAL COMMENTS: if <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE z <br /> 117.7 _ 214 <br /> u I[,hti up,a- 1-74 <br />