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T.. SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE; 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,'2_/07/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Regulations of the San Joaquin Local Health DistO ct. <br /> JOB ADDRESS/LOCATION/ CENSUS TRACT ', F <br /> Owner's Name Phone 7 2 <br /> Address City <br /> Contractor's Name ff License #.Z90,15,41 Phone 9-67 <br /> TYPE OF WORK (Check) : NEW WELL,: DEEPEN/ / RECONDITION /% DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITrPRIVY <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 Cable Tool Dia, of Well Excavation (j r <br /> Domestic/private Drilled - Dia, of`Well <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other .Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type­of Pump' a H.P. . <br /> PUMP REPLACEMENT / / State Work'Done <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 /> WELL DRILLERS REPORT of the 11 ' <br /> and notify them before putting the .well in use. The above <br /> information is true t h est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN ruN. <br /> SIGNED TITLE <br /> QjRAW PLAN- ON REVERSE SI ) - <br /> b <br /> FOR DEPARTMENT USE ONLY 04 � <br /> PHASE I <br /> APPLICATION ACCEPTED Bp �►� -DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS4 JUIF AL INSPECTION <br /> INSPECTION BY 4;;;�e7: RATE41E2-Z2 INSPECTION BY DATE <br />