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F06 OFFICE USE: <br />V SAN OAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />(Complete In Triplicate) 11 <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 Joaquii <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION <br />Owner's Name <br />Address S j <br />Contractor's Name !� <br />TYPE OF WORK (Check): <br />wA- C✓,CENSUS TRACT <br />cmc o! CSR t IZ� ne <br />, City mLra <br />PhoneAtrfA <br />NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION %% <br />PUMP INSTALLATION / 7 PUMP REPAIR( PUMP REPLACEMENT /_7 <br />Other /_/ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />Geophysical <br />G - rn1VAIL <br />IF WELL <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />PUMP INSTALLATION: Contractor <br />Type of Pump <br />IPUMP REPLACEMENT: <br />PUMP .REPAIR: <br />' DESTRUCTION OF WELL: <br />N <br />/ / State Work Done <br />JFK State Work Done <br />ruDLL11 UVrM011L WCLL <br />r' <br />CONSTRUCTION SPECIFICATIONS <br />Dia, of Well Excavation <br />(n <br />Dia. of Well Casing <br />(� <br />Gauge of Casing <br />Depth of -Grout Seal <br />Type of Grout <br />Other Information <br />Surface Seal Installed Bv: <br />! r <br />rl <br />Well Diameter <br />Describe Material and Procedure <br />Wc­_+_ <br />Approximate Depth <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 GROWIINGAND AFn INSPECTION. <br />SIGNED TITLE` <br />(DRAW PLOT PLAN ON REVERSE SIDE <br />PHASE I <br />APPLICATION ACCEPTED <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />INSPECTION BY DATE <br />MENT USE ONLY <br />INSPECTION BY <br />DATE <br />