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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•�OP" icE USE: 1601 E. Hazelton Ave. , Stockton, Calif. N� <br /> Telephone : (209) 466-6781 <br /> _pm <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '02 <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. 186b4�uul__' <br /> 2 and the �Rules and Regulations of the San Joaquin Local Health District. <br />\JOB ADDRESS/LOCATION / ENSUS TRACT ' <br /> Owner's NamePhone <br /> Address J C City 46 i <br /> i <br /> 24 z <br /> Contractor's Name License # EP,3 Phoneme <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / j DESTRUCTION. /� _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / �.. � � 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK JW r;-SEWER LINES PIT PRIVY � LA <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER W <br /> . vc� <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 o:Z u <br /> Domestic/private Drillea.- Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �?I <br /> Irrigation Gravel Pack Depth of Grout Seal aad <br /> Cathodic Protection �_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 0. <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump n H.P. , <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well`Diametex 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'coristruction. 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 thewell in use.. The above %-,j <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A INAL INSPECTION. <br /> SIGNED '- TITLE _ &Z <br /> ( W PLOT PLAN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !r✓ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />