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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70T;OFFICE USE: VVV 160 . 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 ze <br /> (Complete In Triplicate) <br /> Application -is hereby made to the Sun 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 /> i County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local' Health Dietrich. <br />'j JOB ADDRESS AOCATION 7I S �I �' f CENSUS TRACT <br /> Owner's Name ) �- Phone <br /> Address !�. <br /> l City <br /> ' License # 7.3 Phone C �� <br /> Contractors Name <br /> TYPE OF WORK (Check): NEW WELL '/7- DEEPEN / T RECONDITION /DESTRUCTION /7 <br /> PUMP INSTALLATION I / PUMP REPAIR'/v/ PUMP REPLACEMENT <br /> Other: <br /> DISTANCE TO NEAREST: . SEPTIC TANK _ - SEWER LINES PIT PRIVY <br /> `SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PRO ERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' <br /> Industrial Cable Tool. Dia, of Well Excavation <br /> r Domestic/private �� Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> j Irrigation "` . Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. t Other Other Information <br /> Geophysical '' Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.. <br /> PUMP REPLACEMENT: , / / ` State Work Done <br /> PUMP '.REPP;IR:" / / State`Work Done r, r � ' <br /> E <br /> Approximate Depth _ <br /> DE&TRUCTION OF WELL: Well Diameter pp <br /> Describe Material -and Procedure <br /> r <br /> r 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 i <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 AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION :BY DATE INSPECTION BY DATE `7 <br /> r ..: <br /> 4 77Yl.17G De.. I -- . <br />