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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOF OFFICE USE: 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 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f AJ , CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> r <br /> Contractor's Name M License # Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/_/ RECONDITION _/ DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR/ f PUMP REPLACEMENT /7 1114 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIES PIT PRIVY <br /> SEWAGE DISPOS FIELD / CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE- DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA IOPs- <br /> Industrial r <br /> � )<1 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 01 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout c2= 2a ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor L_ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 a <br /> WELL DRILLERS REPORT of the we 1 and notify them before putting the well- in use. The above <br /> information A true to theof my knowledge and belief, I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO G U I G D A FI INS CT ION, <br /> SIGNED TITLE ' <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 7 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS Ili/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE A <br /> E H 1426 ya <br /> 7.7 - x <br /> Rey, 1=74 <br />