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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. �f <br /> ! <br /> 7,THIS PERMIT EXPIRES 1YEAR FROM DATE ISSUED Date Issued L <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 CENSUS TRACT <br /> Owner's Name Phone L . -Z' <br /> Address A City . <br /> Contractor's Name ��► License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION J� <br /> PUMP INSTALLATION >7 PUMP REPAIR / / PUMP REPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -, SEWER-LINES, PIVPRIVY <br /> SEWAGE DISPOSAL FIELD1�- CESSPOOL/SEEPAGEfiPIT OTHER <br /> —'-- ROPERTY NP PRIVATE-DOMES Ti-G-WET,L=!=i PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial `t,;� _.., Cable Tool Dia, of Well Excavation <br /> Domestic/private --D-rill°ed Dia, of Well +Casing <br /> Domestic/public !--.I Driven Gauge of Casing f N <br /> Irrigation Gravel Packl . \ Depth of Grout Seal <br /> Cathodic Protection a,Rotary �- ,k,. Type of Grouts <br /> Disposal `"Other Other Information` <br /> Geophysical <br /> �� �� Surface Seal ;Installed By. <br /> PUMP INSTALLATION: Contractor ,,,.. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />.PUMP <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to� coit►p y, with: ali .laws and regulations, of, the San Joaquin".:Local Health District <br /> and the State ofCalifornia pertaining to or regu].ating,well `construction. „Within FIFTEEN DAYS <br /> after completion of my work' on aLh&w�well,�rl,wi1�I'furnish!-the Snn Joaquin% focal 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' GROUT INSPECTION <br /> PRIOR TO GAqUTING AND FI L INSPECTION, <br /> SIGNED TITLE ` <br /> :(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHAS I/FTVAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE6- � <br /> 2M <br />