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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7e—z9 <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 h Rules and Reg a ons of t e an oaq in Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ Phone <br /> Address .1,P esu-t-{' City' <br /> Contractor's Name �� � License Phone <br /> l <br /> TYPE OF WORK_ (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7AL <br /> PUMP INSTLATION: ./ / PUMP-REPAIR-/ /_ PUMP ..REPLACEMENT ,R. <br /> I . <br /> Other <br /> DISTANCE�TO NEAREST: SEPTIC TANK SEWER LINESP4 PIT PRIVY <br /> 'r•. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER " + <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> jlNTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia, of Well Excavation <br /> r 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�j� <br /> Type of Pump H.P. <br /> 1 PUMP REPLACEMENT: / State Work Done lk�a7r / <br /> 'PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 AL 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 INSITECTION. PHAS III/FITAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7Z, <br /> ` 7 _ 2M <br />