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_.e- , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> iOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ':- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application io• hereby :Wade 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. 1861an *h Rules ons u tions of the San Joaquin Local Health District. <br /> - i <br /> JOB ADDRESS/LOCATION C 7' CENSUS TRACT <br /> Owner's Name a ,, ,. Phone 377 <br /> Address �' f l �` .�:k :"' �. . ' � _ City ' <br /> Contractor's Name 022 Lice Phon+ ,� / <br /> TYPE OF-WORK (Check): NEW WELL/Z7—DEEPEN RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /— PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other j / x. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELDCESSFOOL/SEEPAGE PIT "' OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC"DOMESTIC WELL � I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS v <br /> Industrial —1,=—Cable Tool Dia. 'of Well Excavation ? <br /> `Domestic/private Drilled Dia, of Well Casing = -$••: <br /> Domestic/public Driven "~ Gauge of Casing, /_2° <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> "•►' Cathodic Protection Rotary, kType of Grout ' <br /> Disposal. Other "Other Information <br /> Geophysical Surface Seal Installed 'B r <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / j State Work Done ? <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ti <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GWIN.Q AND A FINAL INSPE ON. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - f <br /> APPLICATION' ACCEPTED BY-. DATE ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION J <br />.`INSPECTION BY DATE INSPECTION BY DATE <br />