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Q� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:O ICE USE: V/ <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1. 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 /> end/or install the work herein described. This application is grade in compliance with San Joaquin, <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Stealth District. <br /> JOB ADDRESS/LOCATION <br /> r CENSUS TRACT , <br /> .a <br /> Owner's Name KAM rr� Phone ' <br /> Address City ' <br /> I <br /> Contractor's Name <br /> License U Phone a <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '17 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / .PUMP REPAIR/_7 PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 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 .,. . <br /> Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �eg- H.P. <br /> �- <br /> ue <br /> PUMP REPLACEMENT: . Ll State Work Done <br /> PUMP ,REPAIR: K7 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 well and notify them before putting.the..well. in.use... .The above <br /> information is true to the•best-of. my..knowled e a d b6fie- I W;LL CALL FOR A GROUT INSPECTION' f <br /> PRIOR TO GROTrMNG AND AIN SPE.CTION <br /> SIGNEDrwaw <br /> a� M <br /> (DRAW PWtrPLAN ON REVERSE E ' <br /> E2gAEPARTMENT USE ONLY <br /> PHASE I <br /> AP.PLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION PHAS I AL NSPECTIDN <br /> INSPECTION BY DATE INSPECTION B DATE <br />