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i J!' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FUL;*OFFICE USE: 1601 E. Hazelton Ave. ,_,.Stockton, Calif. <br /> Telephone: x`('`209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date IssuedQ <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 imd the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone , C e2_ . <br /> Address City :J-dg_Y -- <br /> Contractor's Name License # PhoneS <br /> TYPE OF WORK (Check) : NEW WELL.'a DEEPEN '/7 RECONDITION %f DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> W <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t 1 <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 Cable Tool, Dia. of Well Excavation <br /> Domestic/private (_ Drilled Dia. of Well Casing 'E <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: . / / State Work Done <br /> PUMP17REPAIR: / / State Work Done <br /> DE&TRUCTIONOF_ 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 # <br /> information is true to the-best• my.knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION -: <br /> PRIOR IN D AL S ECTION. ` <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE--- - -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:- <br /> PHASE <br /> OMMENTSrPHASE II. GROUT INSPECTION PHASE III AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br />