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SAN JOAQUIN LOCAL HEALTH DISTRICT FK_ <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-.6781 `��3 <br /> II APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d <br /> If 1 <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 CENSUS TRACT <br /> Owner's Name r- Phone z —,�_ <br /> Address �� i� . 4. City v <br /> Contractor's Name LVM I # e f`c ti License Phone i,14 <br /> i <br /> '^e <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> i' PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �, rrigation Gravel Pack Depth of Grout Seal a <br /> Cathodic. Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ;( Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: State Work Done , <br /> PUMP .REPAIR: /' } State Work Done <br /> .M <br /> DES-TRUCTION OF WELL': Well Diameter Approximate Depth <br /> !I Describe Material and Procedure <br /> 'i <br /> i� <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 GROUTING AND A FI AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �M <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> : PHASEI,JI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ii DATE INSPECTION BY 1061 DATE - "- _ <br /> I1-"7 _ 0,x%7 2M <br />