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s.efr -4 <br /> Nor <br /> * SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f <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 Joaquic': <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION car CENSUS TRACT <br /> Owner's Name Phone <br /> Address City c � <br />. Contractor's Name License #hone <br /> F <br /> TYPE OF WORK (Check) : NEW WELDDEEPEN'/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR `/ / PUMP REPLACEMENT <br /> Other :v / T <br /> DISTANCE TO NEAREST: SEPTIC-TANK &�W 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 /> Industrial F Cable Tool Dia.,of Well Excavation A19 <br /> ,X Domestic/private Drilled --Dia. of Well Casing J'� � C4 <br /> C Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack- Depth of Grout Seal d <br /> Cathodic Protection Rotary { ` Type of Grout <br /> .Disposal i Other , /{ Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> y 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 <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 well and notify them before putting the. well in use.... The above <br /> information is.;truew,to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO>GROUTIN -D A FINAL TWOE,qTWN. <br /> SIGNED `- TITLE <br /> " 1I?RAW-PTOT PLAN ON REVERSE SID ) <br /> F R D PARTMET SE ONLY <br /> PHASE I�> <br /> t APPLICATION, ACCEPTED BY";�. <br /> l Cr` DATE Al/c 0 <br /> ADDITIONAL `•COMMENTS;f� <br /> '� 4P.HASE II'"GROUT INSPECTIO INSPECTION <br /> PHASE / INAL <br /> INSPECTION SYS:' . DATE INSPECTION BYDATE <br /> ' n/77 _ 2M <br />