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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. e <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 Joaquin,, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ rlZ< 'f 6�P CENSUS TRACT <br /> Owner's Name /~ dL �' Phone <br /> Address xzp City <br /> Contractor's Nameff,�/ZT License JjZZ4 PhoneF�� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST,/:?SEPTIC TANK 13 0 SEWER LINES PIT PRIVY <br /> p�ayOd e SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Q 1/ PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial & Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 14 <br /> Domestic/public Driven Gauge of Casing .2_ <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 /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: + ' ./ / State Work Done <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> r <br /> Describe Material and Procedure <br /> i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Di.str' t <br /> and the State of California pertaining to or regulating well �'construction. Within FIFTEEN DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> f PRIOR TO GR U ING AND_A FIN INSPECTION. <br /> r SIGNED TITLE <br /> k DRAW PLOT PLAN ON REVERSE SIDE <br /> kf=T <br /> T USE ONLY <br /> i PHASE I ~� � <br /> APPLICATION ACCEPTED BY DATE /777 <br /> ADDITIONAL COMMENTS: <br /> PHA INSPECTION PHASE �/ INSPEC ION <br /> INSPECTION BY DATE INSPECTION BYDATE — `�� <br />