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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> [C-g_-.OFFICE USE: 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) <br /> F.�jplication is kereby made to the San Joaquin Local Health District for a permit' to construct <br /> ad/or install the work herein described. This application is made. in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dist#ct. <br /> i <br /> F3B ADDRESS/LOCATION C>�. r CENSUS TRACT <br /> mer s Name Phone ' <br /> Address [p G , City <br /> �ntractor's Name License Phone <br /> CP <br /> r.'PE OF WORK (Check) : NEW�•J WELL '/—/ DEEPEN '/—/ RECONDITION /_7 DESTRUCTION //_74 }PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other--�/- ----- -- - -- -- cr- <br /> F, ;STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY GJ <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 <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 BV: _ <br /> I-MP INSTALLATION: Contractor <br /> a. _. . . Type of Pump H.P. <br /> ..- <br /> PAIMP REPLACEMENT: / / State Work Done <br /> PGMP :REPAIR: / f State Work Done , <br /> f r- <br /> 3 S-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ]'hereby agree to comply with all laws and regulations of the Satz Joaquin Local Health District <br /> -?d 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 /> WRLL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> iformation is true to th best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING AND ,A AL INSPECTIO . <br /> SZ,GNED TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE) — �"- <br /> -`s FOR DEPARTMENT USE ONLY <br /> ?MASE I <br /> } PLICATION ACCEPTED BY _ — DATE Z-31-2A <br /> k—DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION .' <br /> jI—SPECTION BY DATE INSPECTION BY E DATE 3wm <br />