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L�? SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� OF ICE 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 /> 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 Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone ��57/ <br /> Address ,,J City �� <br /> Contractor's Name License 4�` _2�,;L--Phone �1: <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR Y PUMP REPLACEMENT /-7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LINES PIT PRIVY c= <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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpAk H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done r-t�ob/ �j,t✓��, ��L d �- <br /> ,�ESTtUCTION OF 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 <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 an_d - ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOU ING AND FINAL INSPECTION, (-'\ <br /> SIGNED �` TLE <br /> (DRAW L T P N REV S$ SIDE) <br /> PHASE I F0 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE7- <br /> 7 y <br />