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SAN JOA LOCAL HEALTH DISTRICT <br /> Fb�10FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 n <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r <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 Districts a permit to construct <br /> and/or install the work herein described. This application is madejh compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San oaquin Local Health District. <br /> IJOB ADDRESS/LOCATION ' CENSUS TRACT <br /> Phone ` <br /> Owner's Name City <br /> Address Address <br /> License #.%Z�e�Phone <br /> ' Contractor's Name ! <br /> ,, TYPE OF WORK (Check) : NEW WELL I DEEPEN / / RECONDITION /� DESTRUCTION f� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other. / / w �+ <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 /> 1 Industrial Cable Tool Dia. of Well Excavation <br /> k Domestic/private Drilled Dia, of Well Casing G <br /> � Domestic/public---- <br /> - - Driven~ ^"� Gauge o-f~�Casing <br /> Irrigation � <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout J <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> . PUMP REPLACEMENT State Work Done <br /> PUMP .REPAIR: / /', State Work Done <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 wel , I will furnish the San Joaquin Local Health District <br /> ! WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to thelbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG D A FINAL INSPECT N4• TITLE .9 _ i �� 'j <br /> rSIGNED lr <br /> DRAW PLOT PLAN ON REVERSE SIDE) - <br /> F DEPARTMENT USE ONLY <br /> Z14�7,7_PHASE I DATE 7 <br /> ,APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS. IT FINAL INSPECTTO <br /> PHASg II GROUT INSPECTION INSPECTION BY - DATE $ a '� <br /> INSPECTION BY DATE <br />