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yJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO��OFF'ICE USE: 1601 E. Hazelton Ave. , Stockton,-Calif. <br /> Telephone: (209) 466--6781 <br /> AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 rein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18 and the Rules a gulations of the San Joaquin Local Health District. <br /> ,per <br /> JOB ADDRESS/LO ON '' -,4, SUS TRACT <br /> Owner's Na Phone <br /> Address j City <br /> Contractor's Name � J tjA_ol License 4/16_>_�3Phone <br /> TYPE OF WORK (Check): NEW WELL F7 DEEPEN '/—/ RECONDITION /? f <br /> DESTRUCTION 1 <br /> PUMP INSTALLATION/ '/ P REPAIR/ PUMP REPLACEMENT" /7 <br /> Other <br /> DISTANCE TO NEAREST: . SEPTIC TANK 'SEWERaINES 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 w.`CONSTRUCTIOR SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation, � <br /> Domestic/private Drilled 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /7 State Work Done ' <br />-PUMP .REPAIR:'- / / State Work Done• <br /> DES-TRUCTION-OF WELL: Well Diameter Approximate Depth <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 a <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 FINAL INSPECTION. <br /> SIGNED TITLE pCj <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> w <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '14DATE '//YV 'Z61 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 4'1>17 <br />