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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 /> j (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 <br /> and Regula�t ons of the San Joaquin Local Health District. <br /> f� <br /> LOCATION <br /> / � <br /> JOB ADDRESS t 7 7 CENSUS TRACT , <br /> J � <br /> Owner's Name Phone <br /> / J i <br /> Address l � � '; City low _ # <br /> Contractor's License #,�Co0a Phone Q ! <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / 1 <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 11� <br /> -µindustrial. Cable Tool Dia, of Well Excavation � <br /> Domestic/private Drilled Dia, of Well Casing <br /> Y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal CA <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractors © <br /> S <br /> Type of Pump V H•P• �- <br /> PUMP REPLACEMENT: State Work Done <br /> -- 4 <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 /> E WELL DRILLERS REPORT of the well and notify them before putting thewell 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 G UTING AN NAL INSPECTION. /wJL <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7 7 <br />