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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F07 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 J I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> (5� HIS 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 Jo4quini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONZ7 �S'+�'�sUS TRACT <br /> Owner's Name Phone d' s <br /> 4 <br /> Address City 5' <br /> I <br /> Contractor's Name # / License Phone , <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN ' _/ RECONDITION / / DESTRUCTION /_7 <br /> r PUMP INSTAL TION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD MECESSPOOL/SE ,PAGE PIT /�Y/� OTHER <br /> PROPERTY_ LINFRIVATE DOMESTIC WELL/�_ PUBLIC DOMESTIC WELL a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS = <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ome s t i c/pr iva t e Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Gi <br /> ,Cathodic -Protection Rotary Type of Grout e <br /> Disposal Other Other Information : <br /> Geophysical , Surface Seal Installed By: __.. t <br /> PUMP INSTALLATION: Contractor Q eoA,-ei <br /> Type of Pump — ^� H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP. PAIR: / / State Work Done <br /> �o �NOFr <br /> DES�TRU WELL: Well Diameter r� Approximate Depth �Q <br /> Describe Materia and Procedure <br /> I hereby agree to comply with all law 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 thein 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 1 <br /> PRIOR TO GROUTING AND I .P..E.CTION. w <br /> SIGNED - TITLEI <br /> (DRAW PLOT PLAN ON- REVERSE SIDE j <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEf <br /> ADDITIONAL COMMENTS: <br /> FHA II GIJOUT INSPECTION �PHASE I I/FIN INSPECTION <br /> INSPECTION BY DATE <br /> l�� ��7 INS ECTION BY fj✓ DATE �-/-7`7/S U /P <br /> R U 169F, ne.. i_7/. <br />