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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOS OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> . <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� , /� CENSUS TRACT <br /> Owner's Name Phone A //.z <br /> Address S' 5� City , . <br /> Contractor's Name J .License &W1�Od' Phone —iz <br /> TYPE OF WORK (Check) : NEW- WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-J I <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / • A . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -- SEWAGE DISPOSAL- FIELD __ - CESSPOOL-/SEEPAGE`PIT_ OTHER , <br /> ___PROPERTY .LINE - .PRIVATE .DOMESTIC -WELL-- - -P-UBLIC DOME ST-1C-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 /> :t? <br /> PUMP REPLACEMENT: State Work Don <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 we11 ''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 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN A IN INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSP TION PHAS I/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -f <br /> 1/27 2 <br />