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. i <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. QIJ <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DACE ISSUED Date Issued _7� <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 n compliance with.-San Joaquin <br />, County Ordinance No. 1862: and the-Rules and Regulationsof .the" Saa ;Jaaquin Local Health•,District. ' <br /> JOB ADDRESS/LOCATION6",eiz 7L,,. CENSUS TRACT bol-7_:aa-W <br /> Owner's Name �v� Phone <br /> Address 9fCity <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN1-7 . RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION {_/ PUMP REPAIR /_7 PUMP REPLACEMENT f7 <br /> Other %{ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL ®Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation J <br /> Domestic/private Drilled .: <br /> 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�` - Other Other Information <br /> Geophysical <br /> Surface Seal Install6d_Byfs� <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump R.P. ' <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR / { State Work Done <br /> DES1RUCTION OF WELL: Well Diameter ` Approximate Depth 0 <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-be 't-of my knowledge and belief. I WILL CALL FOR A GROUT' INSPECTION j <br /> PRIOR TO GROUTINgdND PECTION., 1 <br /> SIGNED , TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USEONLY <br /> PHASE i - - <br /> APPLICATTON ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -" <br /> PHASE II GROUT INSPECTION PHASE III FINAL- INSPECTION <br /> INSPECTION BY DATE MSPECTION BY DATE .E <br /> R 11 1A96; i. Ifte .,nR <br />